MANAGEMENT OF

INFECTED FRACTURES

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PakistanNovember 2015

slides and text available at: www.boneinfection.co.za

THE PATIENT

THE LIMB THE INJURY

THE BACTERIA

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FACTORS

THE PATIENT

Poor General Health:

Metabolic and Auto immune disease

and Immune incompetence

Need radical and aggressive treatment

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THE PATIENT

Polytrauma/Comorbidities

Cardiac, pulmonary, renal

and hepatic impairment

Severe infections elsewhere

All compromise responses

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THE INJURY

Energy of Impact

Impregnated debris

Contamination

THE LIMB

Impaired PerfusionPre-existing arterial and venous disease

Vascular trauma (laceration, thrombosis),

Compression, Needing Fasciotomy

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OVERALL VIABILITY OF LIMB

- Prognosis for residual function

- MESS score & other trauma scores

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THE BACTERIA

Distinguish between

•Commensals and Contaminants

•Colonists and Invaders

•Virulence, local or systemic toxins

•Biofilm, antibiotic resistance

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AFTER ORIF FOR CLOSED

FRACTURES LESS THAN

6 WEEKS OLD

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• Immobilise limb

• Evacuate abscess/haematoma

• Debride necrotic tissue

• Closed irrigation/suction

• Retain effective fixation

• Consider exchange fixation

• Antibiotic therapy

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RATIONALE OF ANTIBIOTIC THERAPY

• Always find bacterial identity and sensitivity

• Choose narrow spectrum gm + ve antibiotic

• Systemic for systemic and well perfused

• Local for poorly perfused tissues

• Surgery for necrosis

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AFTER ORIF FOR FRACTURES

MORE THAN 6 WEEKS OLD

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PRIORITIES IN FRACTURES WITH SOFT TISSUE LOSS OR INFECTION

• Antibiotics for systemic effects ONLY

• Reduce and immobilise bone

• Debride necrotic tissue when demarcated

• Obtain skin cover

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ANTIBIOTICS CANNOT ACCESS

BACTERIA WITHIN NECROTIC

OR POORLY PERFUSED TISSUE

OR WITHIN BIOFILM

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REDUCE AND IMMOBILISE

Retain existing functioningexternal or internal fixation.

External fixation preferred(less invasive - wound access)

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IF MOVEMENT THREATENSIMMOBILISATION

OR CAUSES PAIN WHICH

PREDISPOSES TO DEFORMITY

IMMOBILISE ADJACENT JOINTIN FUNCTIONAL POSITION

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DEBRIDEMENT

Only when clearly demarcated

Skin fat muscle ± 1 week

Ligaments & Tendon ± 4 weeks

Tendo Achilles ± 12 weeks

Bone > 12 weeks

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SOFT TISSUE COVER

Apply expendible split skin graft

when bone and soft tissue

covered by granulation tissue

Avoid complicated composite

local and distant flaps when septic

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BARE BONE

Leave alone till demarcated

or covered by granulation

Provide closed, damp (not soggy)

environment while bone still pink

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Mobilise as best possible

once soft tissue covered

(despite dry bone or sinus)

Patiently await union

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DRAINING SINUSES

• Simple wound toilet

• Tap water, soap and paper towel

• Clean (not sterile) absorbent dressing

• Held by simple non-irritant fixation

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PROMOTE DYNAMISATION

United fibula may inhibit

dynamisation of tibia

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Monitor Blood, X-Ray and

Microbiology every 2 months

THE PATIENT VIGIL

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GIVE UP when

• Fracture solidly united

• New bone can support limb

• No further progress

• Patient insists (economic or social reasons)

• Skin inflammation, itch dermatitis, ulceration

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AS UNION PROGRESSES

Rate of discharge and

blood tests will improve

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WHEN FRACTURE UNITED

Drainage may cease

Consider DRI

(debride, ream, irrigate)

IF NECESSARY

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Remember “degree of infection concept”

Patient may be very well and healthy

despite profusely discharging sinus

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ERADICATION OF INFECTION

Priorities

• Remove hardware and sequestra

• Debride granulation and scar tissue

• Ream full length of medullary canal

• Thoroughly flush surgical field

• Restore soft tissue cover31

WHY REAM TIP TO TIP?

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ERRADICATION OF INFECTION

•Remove all foreign material, all granulation and scar tissue, as well as all non-viable bone•Ream full length of long bones•Thoroughly flush surgical field•Lay double lumen tubes•Restore soft tissue as far as possible

AFTER OPERATION

•Splint to align # and immobilise tubes

•Monitor bacteria and wound volume

•Irrigate and suck till cavity is closed

and free of bacteria

(between 2-4 weeks)

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INFECTED NON UNIONSTALEMATE PERSISTS

Evade infection

Local sequestrectomy

Fibular excision osteotomy

( To promote dynamisation)

Pulsed electro magnetic therapy

Pappineau graft38

INFECTED NON-UNIONSTALEMATE PERSISTS

Confront infection

Two stage Programme

1. Radical Debridement Reaming and Irrigation

2. Fix and maybe graft or

3. Fibular bypass with fixation (variations)

Implants and grafts may lead to re-infection39

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If soft tissues cannot be closed primarily after adequate surgery

•Lay irrigation tubes in medullary canal•Close soft tissue as far as possible without tension•Cover with adhesive plastic (e.g. Opsite Tegaderm)

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If wound not fully closed

Seal with adhesive plasticair tight and water tightwith soft padding and POPInstillation and suction as usualMonitor volume and bacteriaInspect at 3 weeks forgranulation tissue covering bonethrough plastic – no need to expose

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• If bacteria controlled and wound filled in• Plastic surgery as appropriate to restore soft tissue cover• Continue local antibiotics through intramedullary tubes

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IF FRACTURE NOT UNITED AND THERE IS NO SHORTENING

Fix fracture and maybe graft

When soft tissue cover restored

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If fracture gap is up to 2 cms

TibiaPosterior approachCut and transpose fibula to tibiawhile closing tibial gapFix together with fully threaded spongeosaAdd semitubular plate if fibula looks weakApply autogenous bone graftLocal antibiotic and suction drainagePOP cast 2-4 months (weight bear)

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If fracture gap is us to 2 cms

Femur, humerus – allow to shorten After debridement, reaming & irrigationRadius and ulna – match lengths and plate

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If tibial defect more than 2 cmsand fibula is intact, apply bypass graft and screws proximally and distally but pass connecting screws through low profile plate

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Full width defect over 5 cms

Without callus bridge or neighbourRadical DRI bone and soft tissueComfortable soft tissue closurePlaster splint while irrigatingAllow bone to approximate graduallyover 4 weeksAvoid acute shortening

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Fix shortened bone with nailMobilise muscles and jointsWhen united lengthen over nailWhen length corrected, lock nail(exchange for longer nail prn)Remove XFX (after weeks not months)

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Dec 201364

Jan 201465

April 201566

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COBUS ERASMUS

ILIZAROV PRINCIPLES

Distraction/compression

Excise pathology en bloc and transport bone to close gap while opening new gap by callotasis

Acute shortening and lengthening by callotasis at another site

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OTHER TECHNIQUES

Pappineau for infected fracture with skin defect

Masquelet for bone defect withclosed soft tissue cover

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ALL THESE TECHNIQUES CAN BE

ENHANCED BY BEGINNING WITH

A THOROUGH AND METICULOUS

DEBRIDEMENT, REAMING AND IRRIGATION

slides and text available at: www.boneinfection.co.za