- See:
tibia fracture menu (
open tibia fractures);
- Discussion:
-
worst prognostic feature for healing of tibial frxs is infection;
-
osteomyelitis of tibia &
infected non unions are among the most severe complications after tibial frx, & may lead to
amputation;
- probability of infection is related to severity of the trauma (see
Gustillo classification) and condition of the local environment
and systemic compromise of the host
Cierny classification);
- infection is most frequent after high velocity, open injuries w/ skin necrosis or skin loss & after ORIF w/ failed flaps or skin coverage;
-
bacteriology:
- note that the most frequently identified organisms in open tibial fractures are
staph aureus and nocosomial organisms;
- ref:
Accuracy of cx of material from swabbing of the superficial aspect of the wound and needle bx in the preop assessment of osteomyelitis.
- biofilm:
- an aggregation of microbe colonies contained within an extracellular polysaccharide matrix (glycocalyx) which is adherent to the
surface of metal implants or devitalized bone;
- references:
-
Pathophysiology of Infections After Internal Fixation of Fractures.
-
Bacterial adherence to biomaterials and tissue. The significance of its role in clinical sepsis.
-
Application of a rat osteomyelitis model to compare in vivo and in vitro the antibiotic efficacy against bacteria with high capacity to form biofilms.
- Radiographic Studies:
- look for bone resorption, periosteal or endosteal new bone formation, cortical irregularities, and
sequestrum;
- involucrum: reactive new bone which is formed inorder to contain the infection;
- sinograms may delineate extent of infected area;
- CT and/or
MRI may be useful in some situations;
- references:
-
Disease activity in osteomyelitis: role of radiography.
-
Current concepts in posttraumatic osteomyelitis: a diagnostic challenge with new imaging options.
-
Osteomyelitis: characteristics and pitfalls of diagnosis with MR imaging.
- Treatment Considerations:
-
antibiotics:
- preoperative, intraoperative, and postoperative antibiotic treatment will lower incidence of deep wound infections;
-
acute frx debridement: and management of sequestrum
-
pressure irrigation:
- references:
-
Osteomyelitis in grade II and III open tibia fractures with late debridement.
-
soft tissue management:
-
wound management and
contaminated wound care:
-
antibiotic bead pouch placed in bony defects;
-
wound vac
- references:
-
Local antibiotic therapy in the treatment of open fractures and osteomyelitis.
-
Newer methods of antimicrobial delivery for bone and joint infections.
-
Negative pressure dressings as an alternative technique for the treatment of infected wounds.
-
soft tissue coverage: soft tissue coverage may be necessary for large defects;
-
tibia fracture fixation (
open tibia fractures);
-
IM nailing:
- if nail removal is required, then consider reaming canal after nail removal as a method of debridement;
- see
addition of antibiotics to cement
- references:
-
Infection after intramedullary nailing of the tibia. Incidence and protocol for management.
-
Diagnosis and management of infection after tibial intramedullary nailing.
-
Infection after reamed intramedullary nailing of the tibia: a case series review.
-
Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases.
-
The antibiotic cement nail for infection after tibial nailing.
-
Antibiotic Cement-Coated Interlocking Nail for the Treatment of Infected Nonunions and Segmental Bone Defects.
-
external fixators:
- provides easy access to wounds during bone healing;
- w/ osteomyelitis, internal fixation may be left in place if it is stable until fracture healing takes place;
-
circular wire fixators: (see
management of tibial bone defects)
- when Ilizarov is used in conjunction w/ radical resection and
distraction histiogenesis, majority of patients
can expect at least one minor complication;
- bone union averages 6 months once intercalary segments come into contact;
- references:
- Use of Ilizarov Technique for Treatment of Non-Union of the Tibia Associated w/ Infection. JBJS Vol 77-A, No 6. June 1995.
-
The prevention of infection in open fractures: an experimental study of the effect of fracture stability.
- management of tibial bone defects:
-
bone grafting:
- posteromedial or
posterolateral bone grafting can be done w/o disrupting
non unions if alignment is satisfactory;
- references:
-
Results of bone grafting for infected tibial nonunion.
-
Antibiotic-impregnated autogenic cancellous bone grafting is an effective and safe method for the management of small infected tibial defects: a comparison study.
-
management of the infected non union:
- an infected non union is a relative indication for
amputation;
- references:
-
Treatment of sequestra, pseudarthroses, and defects in the long bones of children who have chronic hematogenous osteomyelitis.
-
Infected Nonunion of the Tibia.
Results of treatment of tibial and femoral osteomyelitis in adults.
The influence of skeletal implants on incidence of infection. Experiments in a canine model.
Long-term results of multiple-stage treatment for posttraumatic osteomyelitis of the tibia.
The management of chronic osteomyelitis using the Lautenbach method.
Outcomes in open tibia fractures: relationship between delay in treatment and infection.
Posttraumatic tibial osteomyelitis: a comparison of three treatment approaches.
The Treatment of Chronic Open Osteomyelitis of the Tibia in Adults.
