Synopsis of Orthopaedic Trauma Management. Brian H. Mullis

      Fig. 6.3 Treatment algorithm for acute infection following internal fixation for trauma. ORIF, open reduction and internal fixation.

      3. Known pathogen susceptible to antibiotics.

      4. Stable implant.

      E. Predictors of treatment failure include:

      1. Intramedullary rod placement.

      2. Smoking.

      3. Pseudomonas infection.

      F. Biopsy

      1. Several deep tissue samples should be taken.

      a. These should be taken as far apart as possible to represent the entire wound.

      b. Superficial swabs may only identify local flora and are discouraged.

      G. Factors that prompt implant removal

      1. Persistent infection.

      2. Loose hardware.

      3. Fracture displacement.

      H. If implants are removed prior to fracture healing, ensure that fracture stabilization is achieved.

      1. Splinting.

      2. Revision internal fixation.

      3. External fixation.

      I. If implants are removed and bone resection is necessary

      1. External fixation

      a. Place antibiotic spacer and proceed with Masquelet technique.

      b. Bone transport.

      VII. Outcomes

      A. Implant retention—success rates of curing early postoperative infection with maintenance of hardware range from 68 to 90% with surgical debridement and treatment with culture-specific antibiotics.

      1. Consider elective removal of hardware after bony union.

      B. Implant removal—successful eradication of infection reaches 92% before bony union.

      1. Must outweigh the benefits of fracture stabilization.

      2. Consider an alternative method of fracture stabilization.

      C. Factors increasing risk of treatment failure.

      1. Smoking.

      2. Pseudomonas infection.

      3. Intramedullary nail (IMN).

      4. Tibia.

      5. Need for two or more debridements.

      VIII. Complications

      A. Recurrence of infection following successful bony healing requires removal of hardware, debridement, and treatment with antibiotics.

      B. Infected nonunion

      1. Removal of hardware, aggressive debridement.

      2. Culture-directed antibiotic treatment for 6 weeks.

      3. Repeat open reduction and internal fixation versus external fixation.

      C. Septic arthritis.

      D. Osteomyelitis.

      E. Amputation.

      IX. Special Considerations—Pediatric Population

      A. Concern for septic arthritis due to bacterial seeding.

      B. Inability to ambulate with a remote history of trauma may suggest infection.

      Conclusion

      Infection after internal fixation of fractures is one of the most common complications. Infections significantly increase the cost and the morbidity of an injury. By following standardized diagnosis and treatment regimens outcomes can be optimized. Surgeons need to assure diagnosis of infection, optimize the patient by improving host factors as much as possible and utilizing a multidisciplinary team. A thorough operative debridement of all necrotic and infected tissue is critical. The surgeon then needs to decide to retain or remove implants with a immediate or staged revision fixation. Antibiotics should be culture driven if possible and can be administered intravenous or by oral methods. Adequate soft tissue coverage may require a rotational or free flap. Without a standardized process and multidisciplinary team patients are at risk for persistent infection and/or amputation.

      Suggested Readings

      Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA, Bosse M; Southeast Fracture Consortium. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am 2010;92(4):823–828

      Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350(14):1422–1429

      Lawrenz JM, Frangiamore SJ, Rane AA, Cantrell WA, Vallier HA. Treatment approach for infection of healed fractures after internal fixation. J Orthop Trauma 2017;31(11):e358–e363

      Meehan AM, Osmon DR, Duffy MC, Hanssen AD, Keating MR. Outcome of penicillin-susceptible streptococcal prosthetic joint infection treated with debridement and retention of the prosthesis. Clin Infect Dis 2003;36(7):845–849

      Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair: management with hardware in place. Clin Orthop Relat Res 2008;466(2):466–472

      Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg Am 2013;95(15):1409–1412

      Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. J Bone Joint Surg Br 2005;87(2):249–256

      Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE; Foreign-Body Infection (FBI) Study Group. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. JAMA 1998;279(19):1537–1541

      7 Nonunion and Malunion

       David B. Weiss and Michael M. Hadeed

      Introduction

      The goal of orthopaedic fracture care is to treat fractures in a way that minimizes complications while maximizing functional outcomes. This includes both operative and nonoperative management.

      Bone healing is typically robust and dependable; however, it can fail. When it does, it can result in a nonunion or a malunion. It is critical to understand both the natural history and effect of interventions on bone healing as operative indications are often based on the ability to decrease the chance of nonunion and malunion.

      When a patient develops a nonunion or a malunion, the cost to the health care system and society is great, as it typically results in multiple surgical procedures and extended time away from normal activities. A tibial nonunion has been compared to having an effect on health and wellbeing similar to some cancer or other chronic illness diagnoses.

      To understand malunions and nonunions, it is critical to have a basic understanding of bone healing and the biomechanics of fracture repair (discussed in depth in Chapter 1, Physiology of Fracture Healing, and Chapter 4, Biomechanics of Internal Fracture Fixation). When approaching these difficult cases, it is important to have a stepwise, reproducible approach, make the diagnosis using the history, physical exam, laboratory and radiographic data. Try to determine the causative