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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.