Infected nonunion2

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  • 2. NON UNIONA state in which healing process comes to a halt as judged byclinical & x-ray evidence, beyond the stipulated period ofhealing for a particular bone due to mechanical or biologicalfailure , with a gap being filled with fibrous or dense fibrocartilaginous tissue requiring a change in treatment.
  • 3. INFECTED NONUNIONThat state existing after considerable time [6-8 months] haselapsed, when there is no evidence that fracture will uniteand infection still persists. Therefore other method oftreatment to be done to achieve union and eradicateinfection.
  • 4. PROBLEMSMultiple sinusesOsteomyelitisBone and soft tissue lossDisuse OsteoporosisAdjacent joint stiffnessComplex deformitiesLimb length inequalitiesMulti-drug resistant polybacterial infections
  • 5. Tibia most common siteOpen fracture with infection most common causeInfection following ORIF of closed #.
  • 6. PATHOGENESISINOCULATIONVirulence of microbeSuboptimal condition of the local environmentSystemic compromise of the host.
  • 7. Infection perse doesnt cause nonunionOM thrombosis of blood vessel of haversian canals bone sclerosis and dead bone.Butterfly fragments become sequestrii, isolated & devitalizedby pus & infection granulation tissue.
  • 8. Infection granulation tissue Osteolysis gaps nonunion.Osteolysis occurs around the implants loosening instability of fixation nonunion.Infection causes nonunion earlier than non-infected pts.
  • 9. BIOFILMKey for the development & persistence of inf.Aggregation of microbes enclosed with in an extracelluarpolysaccharide matrix [glycocalyx] that adheres to the surfaceof the implants or devitalized bone.59% of orthopaedic biomaterial related infections +vefindings.
  • 10. Protects the organism from antibiotics and host defensemechanism.Allows the infection to exist in sub clinical state and recur.Implants promotes biofilm, infection would persist.
  • 11. MICROBIOLOGYStaphylococcus aureas most common, [alone or incombination in 65-70%].Pseudomonas aeroginosa [20-37%]Commonly polymicrobial [32-70%].Atypical mycobacterium & fungi in immunocompromisedpts.
  • 12. CLASSIFICATIONInfected nonunion comes under Cierney type IV chronicosteomyelitis ie; there unstable before and afterdebridement.
  • 13. ROSEN et al [AO manual]Infected non-draining nonunionInfected draining nonunion.
  • 14. Infected nondraining nonunionQuiescent ( dry, nondraining for at least 3 months)Needs one stage treatment.Active ( non draining but abscess & fever).Needs two stage treatment.
  • 15. Infected draining nonunionI STAGE: By pass bone grafting [fibular protibia,posteromedial femur or humerus grafting.II STAGE: By pass has become solid radical debridement& open/closed irrigation & antibiotics.III STAGE: cancellous B.G, muscle or skin pedicle flap,
  • 16. G.S KULKARNI classificationSeverity of infectionApposition of fragmentsPresence or absence of deformity.
  • 17. TYPE I: fragments in apposition with mild infection andwith or with out implant, stable implant insitu withmild infection.TYPE II: Fragments in apposition with severe infectionwith large or small wound.TYPE III: Severe infection with a gap or deformity orshortening.3A defect with loss of full circumference3B defect in > 1/3 of cortex3C infected nonunion with deformity.
  • 18. CLINICAL EVALUATIONPain, erythema, swelling, draining sinuses, abnormalmobility.No FeverInfection is clinically silent.High index of suspicion esp in atrophic nonunion.0.2-1.6% chronic draining sinuses S.C.CSuspect when change in pain / discharge.
  • 19. INVESTIGATIONElevated ESR & CRP,Normal WBC.X RAY:1] Quality of bone2] Type of implant3] Fracture healing status4] Angular alignment.
  • 20. Areas suspicious of infectionBone resorptionSequestrum & involucrumPeriosteal & endosteal new bone formationCortical irregularities.
  • 21. DisadvantagesDue to distorted anatomy due to traumaPhysiological reaction of bone to injury.Presence of implants.Cant reliably differentiate between septic and asepticchangesSerial x rays, sensitivity-14%, specificity- 70% in diagnosingactive infection.
  • 22. C.T SCANBetter cortical bone detailsSequestrumSubtle cortical erosionBest detail of bone structure for planning.No artifact with implants.
  • 23. MRIHighly sensitive modality. 98% sensitivity, 75% specificity.Gadolinium enhanced MRI: allows discrimination of activeinfection from artifacts and fibro-vascular scar.Demonstrate sinus tracts, differentiate bone & soft tissue inf,extent of bone involvement.
  • 24. NUCLEAR IMAGING STUDIES Tc-99 M high sensitivity but low specificity15%Ga-67 more specific.Indium 111 labeled WBC scan: sensitivity 83%, specificity86%.Labor intensive, increase radiation dose, 24 hr delay, lowresolution image, in-vitro label.
  • 25. IMMUNOSCINTIGRAPHYInj of radiolabelled murine monoclonal anti-granulocyte ABthat binds WBC antigen.Sensitivity: 93%, specificity: 89%.In-vivo labeling.
  • 26. CULTUREGold standardPrior antibiotic treatment and improper handling ofspecimens preclude the growth.Multiple intra-op specimens: sinus tract, purulent fluid, softtissue, curetted bone, bed of the involved bone.Different micro enviroments.
  • 27. PRINCIPLESPrompt diagnosis and aggressive RxInfection control with surgical debridement and specificantibiotics.# stabilisationSoft tissue coverageRestoration of bone defects.
  • 28. GOALS(1) the infected tissues must be resected to live margins; (2) the methods must address previous fixation failuresand structural deficiencies;(3) the patient must have the potential to heal, survivetreatment, and benefit from treatment; and(4) the prognosis for success must be reasonable and themethods within the capabilities of the medical team
  • 29. METHODSConventional or classic methodActive or modern methodPulsed electromagnetic fieldsIlizarov method.
  • 30. CONVENTIONAL METHODTo convert an infected and draining nonunion in to onethat has not drained for several months and then topromote bone healing by bone grafting.More time consuming.Stiffness of adjacent joints.Reconstructive procedures should be delayed until atleast 6 months after all signs of infections havedisappeared.
  • 31. POSTEROLATERAL GRAFTINGTo avoid the active draining sinuses and poor skin in theanterior aspect.Posterior aspect of the tibia is roughened superior andinferior to nonunion.Entire area is covered with graft.Nonunion site is not exposed.
  • 32. ACTIVE METHODTo obtain bony union early and thus shorten the period ofconvalescence.To preserve the motion in adjacent jts.Restoration of bony continuity- I step.Bone union takes priority over infection.Nonunion exposed through old scars and sinuses.
  • 33. The ends of the fragments are decorticated subperiosteallyosteoperiosteal flaps.All devitalized and infected bone and soft tissue wereremoved.Fragments aligned and stabilised ext.fix.If necessary a second decortication with or with out B.Gcarried out.
  • 34. ILIZAROV METHODTo eliminate infection and to achieve union vascularity mustbe increased.By corticotomy and circul