original papers - Advances in Clinical and Experimental Medicine

ORIGINAL PAPERS
Adv Clin Exp Med 2007, 16, 3, 403–409
ISSN 1230−025X
© Copyright by Silesian Piasts
University of Medicine in Wrocław
PAWEŁ REICHERT1, ROMAN RUTOWSKI1, 2, JERZY GOSK1, KRZYSZTOF ZIMMER1,
ROMAN WIĄCEK1
Treatment of Infected Nonunion of Long Bones
Leczenie zakażonych stawów rzekomych kości długich
1
2
Department and Clinic of Traumatology and Hand Surgery, Silesian Piasts University of Medicine in Wrocław, Poland
Department of Medicine of Sport, Wrocław University of Physical Education, Poland
Abstract
Background. Despite advances in contemporary orthopedics, nonunion of long bones is still a major problem. In
an infected nonunion we must treat osteomyelitis and nonunion together.
Objectives. The purpose of the study was to evaluate the results of treating infected nonunion of long bones by
local antibiotic bead chains (Septopal−gentamicin) with autogenous bone graft.
Material and Methods. Fourteen patients were treated between 2001–2005 at the Clinic of Traumatology and
Hand Surgery, Silesian Piasts University of Medicine in Wrocław, because of infected nonunion of a long bone.
The time from fracture to operation was from 6 to 18 months. According to the Cierny−Mader classification of
osteomyelitis, 6 patients were in stage IVA, 4 in stage IVB, and 4 in stage IIIA. The size of the defect before bone
grafting ranged from 2 to 5 cm. The duration from debridement to bone graft ranged from 4 to 10 weeks.
Results. Bone union was achieved in 10 of the 14 patients. The mean time of bone union achievement was
9 months. Union in cases of IVB of the Cierny−Mader classification were usually not obtained.
Conclusions. Use of antibiotic bead chains with cancellous bone graft produced satisfactory results in the treat−
ment of infected nonunion. The treatment results of infected nonunion depended on the kind of osteomyelitis in the
Cierny−Mader classification (Adv Clin Exp Med 2007, 16, 3, 403–409).
Key words: infected nonunion, osteomyelitis, bone graft.
Streszczenie
Wprowadzenie. Leczenie stawów rzekomych pomimo znacznego postępu technik operacyjnych nadal jest bardzo
trudnym problemem ortopedycznym. W przypadkach zakażonych stawów rzekomych postępowanie terapeutycz−
ne obejmuje zarówno leczenie zapalenia kości, jak i zaburzeń zrostu kości.
Cel pracy. Ocena wyników leczenia zakażonych stawów rzekomych kości długich za pomocą koralików genta−
mycynowych (Septopal) i autogennego wszczepu kości.
Materiał i metody. W latach 2001–2005 w Klinice Chirurgii Urazowej i Chirurgii Ręki AM we Wrocławiu leczo−
no 14 chorych z powodu zakażonych stawów rzekomych kości długich. Czas od złamania do operacji wynosił
6–18 miesięcy. Zapalenie kości według klasyfikacji Cierny−Madera u 6 chorych określono typem IVA, u 4 chorych
IIIA, u 4 chorych IVB. Długość stosowanego wszczepu wynosiła 2–5 cm. Czas od oczyszczenia ogniska zapalne−
go do zastosowania przeszczepu wynosił 4–10 tygodni.
Wyniki. Zrost kostny uzyskano u 10 chorych na 14 leczonych. Średni czas uzyskania zrostu kostnego wynosił
9 iesięcy. Niepowodzenia dotyczyły głównie chorych z typem IVB zapalenia kości.
Wnioski. Leczenie za pomocą Septopalu i autogennego wszczepu kości daje dobre wyniki w przypadkach zaka−
żonych stawów rzekomych. Wyniki leczenia stawów rzekomych zależą od stopnia zapalenia w klasyfikacji Cier−
ny−Madera (Adv Clin Exp Med 2007, 16, 3, 403–409).
Słowa kluczowe: zakażony staw rzekomy, zapalenie kości, wszczep kostny.
Nonunion of a long bone, even in the era of
contemporary orthopedics, still poses a potential
risk to limb integrity. It is not merely a failure of
two bone segments to unite, but most frequently it
represents a significant loss of limb function with
concomitant muscle atrophy, loss of range of
motion of joints, compromise of the surrounding
soft tissue, especially in the presence of infection,
404
P. REICHERT et al.
as well as diffuse osteopenia with occasional scle−
rotic bone ends [1–3]. The management of infect−
ed nonunion is lengthy, very costly, and may have
a lasting impact on the independence and life qual−
ity of those affected [4].
Before we plan to treat a nonunion, we must
know its cause. In an infected nonunion we must
treat osteomyelitis and nonunion together. The tradi−
tional treatment of an infected tibial nonunion is
a combination of adequate surgical debridement, sta−
bilization of the ununited fracture, management of
the nonunion, and soft tissue reconstruction, if nec−
essary [5]. Due to the difficulty in achieving an effi−
cient bone bridge of large bone defects resulting
from repeated radical debridements, different surgi−
cal approaches have been published. Debridement
with incomplete bone resection followed by repeat−
ed local treatment has been described by Papineau
and has commonly been used [6]. In this technique,
following bone stabilization, repeated local debride−
ments follow excision of the infected focus, with
preservation of the posterior bone cortex. Topical
treatments follow and consist of repeated and fre−
quent wet dressings until granulation tissue is
formed in the resected bone. Then, cancellous bone
grafting and delayed soft tissue closure may be
added, but are not necessary [6]. Open cancellous
bone grafting has been used to fill the resulting bone
defect following bone stabilization with either a cast
or external fixation [7]. Other methods to treat
nonunion, including autogenous bone grafts [7, 8],
antibiotic−impregnated autogenous cancellous bone
grafts [9], antibiotic−containing bead chains with and
without autogenous bone grafts [10], bone transport
techniques [11, 12] and free vascularized grafts [13,
14], cancellous bone grafts combined with soft−
−tissue transfer [15], bone stabilization by intra−
medullary nails together with a soft tissue cover by
free muscle flaps [16], and the use of hyperbaric
oxygen [17] to enhance tissue oxygenation, neovas−
cularization, and bone formation, have all been pro−
posed as solutions to achieve bone gap healing.
The bone union result depends very often on
the treatment of osteomyelitis. Osteomyelitis can
be viewed as a triad of interacting forces: microbi−
ological virulence, host physiology, and anatomic
stability [8]. Effective therapy and treatment rely
on addressing each of these factors. Cierny and
Mader’s [8] classification of osteomyelitis is the
most widely used in orthopedic literature. Their
system classifies according to the degree of ana−
tomic involvement and host physiology (Table 2).
Pairing four types of osteomyelitis with three host
classes creates 12 stages of osteomyelitis that can
guide therapy. The treatment depends on the kind
of nonunion and the Cierny and Mader classifica−
tion of osteomyelitis.
The purpose of this study was an evaluation of
the results of treating infected nonunion of long
bones by local antibiotic bead chains (Septopal−
gentamicin) with autogenous bone graft.
Material and Methods
Fourteen patients were treated between
2001–2005 at the Clinic of Traumatology and
Hand Surgery, Silesian Piasts University of Me−
dicine in Wrocław, because of infected nonunion
of long bones. Most of the patients had initially
been treated outside this clinic (83%). In the tested
group, men constituted the majority (75%, 11 men
and 3 women) and the ages of the operated patients
were from 18 to 56, with an average of 41 years.
Nonunion of the tibia were treated in 4 cases, of
the humerus in 4 cases, of the femur in 3 cases, and
of the radius in 3 cases. The time from fracture to
operation, and also usually the duration of infec−
tion, was from 6 to 18 months. During this period
the patients underwent an average of two opera−
tions.
Examination of the patients consisted of sub−
jective examination and as well as radiological,
arteriographic, and scintigraphic studies (Figs. 1, 2)
Table 1. Modified classification of Stewart and Hundley
Tabela 1. Zmodyfikowana klasyfikacja Stewerta i Hundleya
Results
(Wyniki)
Clinical estimation – union, pain, mobility of adjoining joints, damage to nerves
(Ocena kliniczna – zrost, ból, ruchomość sąsiednich stawów, uszkodzenia nerwów)
Very good
(Bardzo dobry)
union, lack of pain, full mobility of adjoining joints
Good
(Dobry)
union, slight pain, limitation of mobility of adjoining joints less than 20 degrees, angular positioning
of bone less than 10 degrees
Satisfactory
(Zadowalający)
union, periodical pain, limitation of mobility of adjoining joints between 20 and 40 degrees, angular
positioning of bone over 10 degrees
Poor
(Zły)
lack of union, pathological mobility, continuous pain, limitation of mobility of adjoining joints over
40 degrees, injury of nerve
405
Treatment of Infected Nonunion of Long Bones
Fig. 1. Patient P.G., age: 29,
humeral nonunion:
a − radiograph,
b − bone scintigram
Ryc. 1. Pacjent P.G., lat 29,
staw rzekomy kości ramiennej:
a – zdjęcie radiologiczne,
b – scyntygrafia kości
a
b
Fig. 2. Patient M.S., age: 32, femoral
nonunion: a – radiograph, b – bone
scintigram
Ryc. 2. Pacjent M.S., lat 32,
staw rzekomy kości udowej: a – zdjęcie
radiologiczne, b – scyntygrafia kości
a
b
Fig. 3. Patient M.W., age: 44, fibrosis tissue with pus
Ryc. 3. Pacjent M.W., lat 44, zwłókniałe tkanki
z wysiękiem ropnym
Fig. 4. Patient M.J., age: 22, implantation of Septopal
in infected nonunion
Ryc. 4. Pacjent M.J., lat 22, wprowadzenie Septopalu
w zakażonym stawie
and showed how extensive the osteomyelitis was.
In their histories, particular attention was paid to
the kind of fracture (open fracture), discontinua−
tion of cutaneous integuments, the initial way of
treatment, and accompanying nerve injuries. All
patients were followed up retrospectively during
control examinations and observation for at least
18 months after bone grafting. Non−achievement
of bone union during 12 months or continued
osteomyelitis was classified as a poor result and
the patient was qualified for further treatment.
Intrasurgical examination was documented by
intrasurgical pictures (Figs. 3 and 4). The Stewart
and Hundley modified classification was used in
the methodology of clinical and subjective evalua−
tion of the patient (Table 1) [24]. Nonunion was
defined as a minimum of six months elapsing and
the fracture showing no visible progressive signs
of healing for three months on serial radiographic
examination [19]. The nonunion was stabilized
with an external fixation device or a cast (two
patients who did not agree to treatment by external
fixation).
According to the Cierny−Mader classification
(Table 2) of osteomyelitis, six patients were in
stage IVA, four in stage IIIA, and four in stage
IVB, including three systemically compromised
hosts and one locally compromised hosts. Eleven
cases of infected nonunion resulted from open frac−
ture and three from closed fractures treated with
open reduction and internal fixation with subse−
quent infection. Preoperative and intraoperative
406
P. REICHERT et al.
Table 2. The Cierny and Mader Staging System [18]
Tabela 2. Klasyfikacja Cierny−Madera
Anatomic type
(Anatomiczny typ)
Description
(Opis)
Stage 1
(Typ 1)
medullary
infection limited to the intramedullary surfaces of bone
Stage 2
(Typ 2)
superficial
contiguous locus of infection
Stage 3
(Typ 3)
localized
full−thickness cortical sequestration that can be removed without compromising bony
stabilization
Stage 4
(Typ 4)
diffuse
through and through infection requiring intercalary resection of bone and loss of stability
Host class
Description
(Klasy prognostyczne pacjentów) (Opis)
A
normal host, normal immune system, normal vascularity
B
systemic compromise (Bs):
malnutrition, renal, hepatic failure,
diabetes mellitus, chronic hypoxia,
immune disease, malignancy,
extremes of age, immunosuppression
C
treatment morbidity worse than present condition, with low prognosis for cure
local compromise (Bl):
chronic lymphedema, venous stasis, major
vessel compromise, arthritis extensive
scarring, radiation fibrosis, neuropathy
Results
cultures were collected from all infected wounds
and deep soft tissue. In the IVA and IVB cases, fis−
tulae without bone exposition were observed. The
most common microorganism was gentamicin−sen−
sitive Staphylococcus aureus; other microorgan−
isms were also sensitive to gentamicin. Irrigation
of the wounds with copious normal saline solution
was performed during each surgical procedure.
Bone grafting was performed after the patients had
received a course of oral antibiotics (teicoplenin)
and were treated by local antibiotic−loaded bead
chains (Septopal−gentamicin) and all tissues were
completely healed. The size of the defect before
bone grafting ranged from 2 to 5 cm. The duration
from debridement to bone graft ranged from 4 to 10
weeks. Depending on the size of the bone defect,
the cancellous bone graft was harvested from either
the anterior or posterior iliac crest.
Data on the patients, the kinds of treatment,
and the results are in Table 2. Bone union was
achieved in 10 of the 14 patients. Very good results
were achieved in 3 patients, 4 patients finished
therapy with good results, and 3 patients with sat−
isfactory results. In 4 cases bone union was not
achieved. The mean time of bone union achieve−
ment was 9 months. Four patients achieved bone
union after 9 months, 3 patients after 6 months,
and 3 patients after 12 months. Examples of
nonunion, the course of bone union, and the times
of achievement are presented in Figures 5 and 6.
Union was not obtained in cases of IV B in Cierny−
Mader’s classification.
Fig. 5. Patient D.M., age: 23, radial
nonunion: a – nonunion, time from
fracture to operation: 12 months,
b – bone union after 6 months, bone
grafting: 2 cm, c – bone union after
9 months
Ryc. 5. Pacjent D.M., lat 23, staw
rzekomy kości promieniowej:
a – staw rzekomy, okres od złamania
do operacji: 12 miesięcy,
b – zrost kostny po 6 miesiącach,
przeszczep kostny 2 cm, c – przebu−
dowa kostna po 9 miesiącach
a
b
c
Fig. 6. Patient G.M., age: 29, humeral
nonunion: a – nonunion, time from
fracture to operation: 6 months,
b – bone union after 6 months, bone
grafting: 5 cm, c – bone union after
9 months
Ryc. 6. Pacjent G.M., lat 29, staw
rzekomy kości ramiennej: a – czas
od złamania do operacji – 6 miesięcy,
b – zrost kostny po 6 miesiącach,
przeszczep kostny 5 cm, c – przebu−
dowa kostna po 9 miesiącach
a
b
c
Table 3. Data on patients, kinds of treatment, and results
Tabela 3. Dane poszczególnych chorych, rodzaj i wyniki leczenia
Case Bone
(Przy− (Kość)
pa−
dek)
C–M
classi
fication
(klasyfi−
kacja
C–M)
Time from
fracture to
operation
– months
(Czas od
złamania
do ope−
racji –
miesiące)
Duration
from debri−
dement to
bone graft
(Okres od
debride−
ment do
przeszczepu
kostnego)
Bone
defect
– cm
(Ubytek
kości –
cm)
Months
for bony
union
(Czas
uzyska−
nia zrostu
kosnego)
External
fixator or
cast
(Stabiliza−
tor zew−
nętrzny
lub unieru−
chomienie
gipsowe)
Result in
Stewart−
−Hundley
(Rezultaty
w skali
Stewart−
−Hundley)
Arrest of
infection
(Eradyka−
cja ogniska
zapalnego)
Compli−
cation
(Powi−
kłania)
–
nonunion
1
humerus
(k. ra−
mienna)
IVB
9
6 weeks
2 cm
–
ext. fixator bad
2
tibia
(k. pisz−
czelowa)
IIIA
9
4 weeks
4 cm
12
ext. fixator very good +
–
3
femur
IVB
(k. udowa)
12
10 weeks
2 cm
–
ext. fixator bad
–
nonunion
4
femur
IVB
(k. udowa)
18
10 weeks
3 cm
–
ext. fixator bad
+
nonunion
5
radius
IVA
(k. pro−
mieniowa)
6
4 weeks
5 cm
6
cast
+
–
6
radius
IIIA
(k. pro−
mieniowa)
9
4 weeks
4 cm
9
ext. fixator satisfac−
tory
+
–
7
humerus
(k. ra−
mienna)
IVA
6
6 weeks
2 cm
6
cast
very good +
–
8
radius
IIIA
(k. pro−
mieniowa)
6
4 weeks
3 cm
6
ext. fixator good
+
–
9
humerus
(k. ra−
mienna)
IVA
9
8 weeks
4 cm
12
ext. fixator satisfac−
tory
+
–
10
tibia
(k. pisz−
czelowa)
IVA
6
10 weeks
3 cm
12
ext. fixator good
+
–
11
tibia
(k. pisz−
czelowa)
IVA
12
6 weeks
2 cm
9
ext. fixator good
+
–
12
femur
IIIA
(k. udowa)
6
8 weeks
3 cm
9
ext. fixator very good +
–
13
tibia
(k. pisz−
czelowa)
IVA
9
6 weeks
2 cm
9
cast
+
–
14
humerus
(k. ra−
mienna)
IVB
12
6 weeks
5 cm
–
nonunion
good
satisfac−
tory
ext. fixator bad
408
P. REICHERT et al.
Discussion
The treatment of infected nonunion is very dif−
ficult because we must treat nonunion as well as
osteomyelitis. Patients need to understand that
treatment potentially involves a long process
requiring multiple operations and significant pa−
tient cooperation. A surgeon faced with challeng−
ing patients needs to be able to diagnose, treat, and
refer these patients when appropriate. The several
methods which are described mean that none is
perfect. The most popular treatment is the Ilizarow
method. The Ilizarov method of bone transport has
advanced the treatment of osteomyelitis and seg−
mental defects. Ilizarow first introduced distrac−
tion osteogenesis as a biological technique for cre−
ating new bone from existing host bone. The main
factors for clinical success are stable fixation and
local hypervascularization [12]. The Ilizarow
approach is based on these cardinal principles:
increase vascularity and stability, correct malalign−
ment and limb discrepancy, and improve function
[11]. Union results in between 70–80% of cases.
The disadvantage of this method is the long time
to achieve union and an uncomfortable stabilizer.
An alternative method is antibiotic−containing
beads with an autologous bone graft. Effective
treatment consists first and foremost of surgical
debridement. To be effective, resection must be
wide, with a margin of viable bone [20]. This
leaves a gap in the affected bone, which is no
longer stable. Stabilization has to be performed
prior to surgical debridement. Bone grafting plays
a critical role in promoting bone healing in an
infected nonunion, although recurrent infection is
of concern [20]. Cancellous bone grafting as an
antibiotic delivery system has been reported as an
effective method to combat infection. A temporary
filling of the dead space with antibiotic beads
before bone grafting was also reported by many
authors [9, 10, 22, 23]. Chin [21] had success in
13 of 18, Paley in 26 of 29, and Cattaneo in 26 of
28 cases. In the present study, union and eradica−
tion of osteomyelitis were achieved in 70% of cases.
However, failures with all methods are not rare, and
failure to achieve bone union healing may become
an indication for amputation, especially in B and
C hosts of the Cierny−Mader’s classification.
The authors conclude that antibiotic bead
chains with cancellous bone graft give satisfactory
results in the treatment of infected nonunion. The
results of treatment of infected nonunion depend
on the kind of osteomyelitis in Cierny−
Mader’s classification.
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Address for correspondence:
Paweł Reichert
Department and Clinic of Traumatology and Hand Surgery
Silesian Piasts University of Medicine
R. Traugutta 57/59
50−417 Wrocław
Poland
E−mail: [email protected]
Conflict of interest: None declared
Received: 31.10.2006
Revised: 7.04.2007
Accepted: 10.05.2007