Tibia Fracture Infections:

- 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 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; 
    - smoking:
            - 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
    - bacteriology:
            - note that the most frequently identified organisms in open tibial fractures are staph aureus and nocosomial organisms;
            - references:
                   - 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?
            - biofilm:
                 - aggregation of microbe colonies with in extracellular polysaccharide matrix (glycocalyx) which is adherent to
                            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 for osteo
           - 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. 
                 - 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
                 - 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. 
                        - 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;
                 - references:
                        - 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;
               - references:
                    - 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;
           - 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.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, March 15, 2016 11:16 am