J Korean Fract Soc.  2017 Jan;30(1):52-62. 10.12671/jkfs.2017.30.1.52.

Treatment Strategy of Infected Nonunion

• Oh HK

• KMID: 2367353
• DOI: http://doi.org/10.12671/jkfs.2017.30.1.52

Abstract

The management of infected nonunion is based on a detailed evaluation of patients, the involved bone and soft tissues, stability of fixation, and type of bacterial pathogens. Preoperative surgical planning and strategies for each step is mandatory for the successful treatment of infected nonunion. The radical debridement of infected tissues, including the unstable implant, is one of the most important procedures. Adequate soft tissue coverage should be considered for the appropriate management of infection; a reconstructive procedure and stable skeletal stabilization by internal or external fixation is also necessary later. A restoration of bone defects and bony union can be accomplished with bone grafting, distraction osteogenesis, vascularized fibular grafting, and induced membrane technique.

Keyword

Long bones; Nonunion; Infection; Surgical treatment

MeSH Terms

Bone Transplantation
Debridement
Humans
Membranes
Osteogenesis, Distraction
Transplants

Figure

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  Fig. 1 A 33-year-old male suffered from open femoral shaft fracture associated with complete femoral artery (arrow).

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  Fig. 2 (A) A temporary external fixation was carried out after wound debridement and vascular reconstruction. (B) External fixation was converted to bridging-plate fixation after soft tissue healing.

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  Fig. 3 (A) Plain X-ray taken 6 months after the injury shows delayed healing of the fracture without implant loosening. Tissue biopsy from the nonunion site revealed an infection, but there was no significant instability of the fracture, and infection was localized around the fracture site. After meticulous debridement of the infected tissue, autogenous cancellous bone graft and plate augmentation was performed. (B) Plain X-ray taken 12 months after revision surgery shows a solid bony union without recurrence of infection.

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  Fig. 4 Open type IIIc distal tibia and fibular fracture of a 31-year-old male was treated with vascular reconstruction and temporary external fixation.

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  Fig. 5 (A) Internal fixation with intramedullary nail was carried out after soft tissue healing. (B) Plain X-ray taken 7 months after the injury shows atrophic nonunion, and there was pus discharge from the previously open wound on the medial side.

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  Fig. 6 (A) Under the diagnosis of infected nonunion, radical debridement of the infected tissue was performed and the fracture was stabilized by an external fixator. The bone defect after debridement was filled by an anti-cement bead. (B) An X-ray from the final follow-up showed a solid bony union after autogenous bone graft and plate fixation.

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  Fig. 7 (A) Clinical photography and X-ray show open comminuted proximal tibia fracture of a 72-year-old male. (B) Due to associated multiple injury, the fracture was stabilized by a temporary external fixator.

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  Fig. 8 (A) An X-rays and clinical photography taken 5 months after the injury showed infected nonunion after definite plate fixation with soft tissue defect. (B) The radical debridement of infected bone and soft tissue was carried out. The bone defect was filled by an anti-cement spacer (induced membrane technique) and soft tissue defect was covered by a free flap.

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  Fig. 9 An X-ray from the last follow-up showed solid bony union after autogenous bone graft and plate fixation after infection control.

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