Management of infected nonunion of the long bones by a multidisciplinary team

Bose, Deepa; Kugan, R.; Stubbs, David; McNally, Martin

doi:10.1302/0301-620x.97b6.33276

Cited by 126 publications

(90 citation statements)

References 26 publications

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“…Infection can present acutely in the first few weeks after internal fixation, in a delayed manner with low-grade infection or late with infected non-union or persistent infection after fracture healing [1–3]. The incidence of deep infection after surgical fracture care is relatively high (between 1 and 19%) [4–6], depending on trauma-related risk factors such as contaminated open fractures, damage control procedures and concomitant soft tissue injuries.…”

Section: Introductionmentioning

confidence: 99%

Accuracy of diagnostic imaging modalities for peripheral post-traumatic osteomyelitis – a systematic review of the recent literature

Govaert

IJpma

McNally

et al. 2017

Eur J Nucl Med Mol Imaging

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AimsPost-traumatic osteomyelitis (PTO) is difficult to diagnose and there is no consensus on the best imaging strategy. The aim of this study is to present a systematic review of the recent literature on diagnostic imaging of PTO.MethodsA literature search of the EMBASE and PubMed databases of the last 16 years (2000–2016) was performed. Studies that evaluated the accuracy of magnetic resonance imaging (MRI), three-phase bone scintigraphy (TPBS), white blood cell (WBC) or antigranulocyte antibody (AGA) scintigraphy, fluorodeoxyglucose positron emission tomography (FDG-PET) and plain computed tomography (CT) in diagnosing PTO were considered for inclusion. The review was conducted using the PRISMA statement and QUADAS-2 criteria.ResultsThe literature search identified 3358 original records, of which 10 articles could be included in this review. Four of these studies had a comparative design which made it possible to report the results of, in total, 17 patient series. WBC (or AGA) scintigraphy and FDG-PET exhibit good accuracy for diagnosing PTO (sensitivity ranged from 50–100%, specificity ranged from 40–97% versus 83–100% and 51%–100%, respectively). The accuracy of both modalities improved when a hybrid imaging technique (SPECT/CT & FDG-PET/CT) was performed. For FDG-PET/CT, sensitivity ranged between 86 and 94% and specificity between 76 and 100%. For WBC scintigraphy + SPECT/CT, this is 100% and 89–97%, respectively.ConclusionsBased on the best available evidence of the last 16 years, both WBC (or AGA) scintigraphy combined with SPECT/CT or FDG-PET combined with CT have the best diagnostic accuracy for diagnosing peripheral PTO.

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Section: Introductionmentioning

confidence: 99%

Accuracy of diagnostic imaging modalities for peripheral post-traumatic osteomyelitis – a systematic review of the recent literature

Govaert

IJpma

McNally

et al. 2017

Eur J Nucl Med Mol Imaging

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“…A multidisciplinary team approach2 works best. The surgical team needs skills in limb lengthening, deformity correction, and bone transport techniques 345678.…”

Section: Introductionmentioning

confidence: 99%

Infected nonunion of tibia

Chaudhary¹

2017

IJOO

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Infected nonunions of tibia pose many challenges to the treating surgeon and the patient. Challenges include recalcitrant infection, complex deformities, sclerotic bone ends, large bone gaps, shortening, and joint stiffness. They are easy to diagnose and difficult to treat. The ASAMI classification helps decide treatment. The nonunion severity score proposed by Calori measures many parameters to give a prognosis. The infection severity score uses simple clinical signs to grade severity of infection. This determines number of surgeries and allows choice of hardware, either external or internal for definitive treatment. Co-morbid factors such as smoking, diabetes, nonsteroidal anti-inflammatory drug use, and hypovitaminosis D influence the choice and duration of treatment. Thorough debridement is the mainstay of treatment. Removal of all necrotic bone and soft tissue is needed. Care is exercised in shaping bone ends. Internal fixation can help achieve union if infection was mild. Severe infections need external fixation use in a second stage. Compression at nonunion site achieves union. It can be combined with a corticotomy lengthening at a distant site for equalization. Soft tissue deficit has to be covered by flaps, either local or microvascular. Bone gaps are best filled with the reliable technique of bone transport. Regenerate bone may be formed proximally, distally, or at both sites. Acute compression can fill bone gaps and may need a fibular resection. Gradual reduction of bone gap happens with bone transport, without need for fibulectomy. When bone ends dock, union may be achieved by vertical or horizontal compression. Biological stimulus from iliac crest bone grafts, bone marrow aspirate injections, and platelet concentrates hasten union. Bone graft substitutes add volume to graft and help fill defects. Addition of rh-BMP-7 may help in healing albeit at a much higher cost. Regeneration may need stimulation and augmentation. Induced membrane technique is an alternative to bone transport to fill gaps. It needs large amounts of bone graft from iliac crest or femoral canal. This is an expensive method physiologically and economically. Infection can resorb the graft and cause failure of treatment. It can be done in select cases after thorough eradication of infection. Patience and perseverance are needed for successful resolution of infection and achieving union.

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“…Conversely, bone necrosis developing early in the disease process limits the possibility of eradicating the pathogen and leads to chronicity (35). Treatment strategies for osteomyelitis mainly consist of three stages, firstly antimicrobial agents, secondly surgical techniques and thirdly amputation (36). A variety of antimicrobial agents with a different spectrum of action, pharmacokinetics and pharmacodynamics have been used in this manner.…”

Section: Discussionmentioning

confidence: 99%