- See: tibia fracture menu
(open tibia fractures
- worst prognostic feature
for healing of tibial frxs is infection;
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 trauma (see Gustillo classification
) and condition of the local environment and
compromise of 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;
- Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures.
- Deleterious effect of smoking on healing of open tibia-shaft fractures
- [Adverse effects if smoking on healing of bones and soft tissues].
- Cigarette smoking and open tibial fractures
- note that the most frequently identified organisms in open tibial fractures are staph aureus
and nocosomial organisms;
- Accuracy of cultures swabbing of superficial aspect of wound and needle biopsy in preop assessment of osteomyelitis.
- What is the Rate of Methicillin-resistant Staphylococcus aureus
and Gram-negative Infections in Open Fractures?
- aggregation of microbe colonies with in extracellular polysaccharide matrix (glycocalyx)
which is adherent to
surface of metal implants or devitalized bone;
- 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;
- 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 for osteo
- preoperative, intraoperative, and postoperative antibiotic treatment will lower incidence of deep wound infections;
- acute frx debridement: and management of sequestrum
- pressure irrigation
- Osteomyelitis in grade II and III open tibia fractures with late debridement.
- Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation
- soft tissue management:
- wound management
and contaminated wound care
- antibiotic bead pouch
placed in bony defects;
- wound vac
- 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
- 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.
- Staged Bone Grafting Following Placement of an Antibiotic Spacer for Management of Segmental Long Bone Defects
- Antibiotic Cement Screw for Postoperative Infection After Gamma Nailing
- Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bones
- 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
, patients can expect at
least one minor complication;
- bone union averages 6 months once intercalary segments come into contact;
- Use of Ilizarov Technique for Treatment of Non-Union of the Tibia Associated with Infection
- The prevention of infection in open fractures: an experimental study of the effect of fracture stability.
- Single-stage surgical treatment of infected nonunion of the distal tibia
- management of tibial bone defects
- bone grafting:
- posteromedial or posterolateral bone
grafting can be done w/o disrupting non unions
if alignment is satisfactory;
- Results of bone grafting for infected tibial nonunion.
- Antibiotic autogenic cancellous bone grafting is an effective and safe method for the management of small infected tibial defects
- management of the infected non union
- an infected non union is a relative indication for amputation
- 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
Original Text by Clifford R. Wheeless, III, MD.