Treatment of infected non union of long bones with use of reinforced antibiotic bone cement rod

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Treatment of infected non union of long bones
with use of reinforced antibiotic bone cement rod
Dr Harpal Singh Selhi Associate
Professor Department of Orthopaedic Surgery
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Therisk of infectionremainsthecrucialissue of
internal fixation Martin Allgöwer, 1975
Today, 35 years later, this statement is still
valid!
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An incidence of infection gt 12 for closed
fractures gt 67 for open fractures (except
Gustilo type IIIB IIIC)
Requires action to revise the protocol of your
fracture management
P Ochsner 1992, Gustilo et al 1987
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Risk factors for surgical site infection

• Host related
• high age
• co-morbidity (diabetes, obesity,
  arteriosclerosis, malnutrition, nicotine, etc)
• drugs (steroids, immuno-suppression,
  antibiotics)
• remote infections (dental, etc)
• preoperative hospitalization
• Procedure related
• emergency operation
• duration of surgery
• surgical technique
• timing of surgery

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Factors contributing to acute infection

• Contamination with pathogenic organisms
• Staphylococcus aureus gt 64
• Presence of a medium for bacteria to grow
• Rough soft-tissue handling, periosteal stripping
• Mechanical instability of fracture
• We can influence all of them

Acute posttraumatic infection starts locally with
or without general symptoms
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How to reduce the risk of contamination

• Staphylococcus aureus are everywhere in our
  hospitals
• Discipline in patient management is essential
• - good cleaning of our hospitals
• - wearing face masks
• - repeated hand disinfection
• - type and time of hair removal
• - correct skin disinfection
• - no small talk during surgery
• - sterile gloves for dressing changes

Strict isolation if MRSA is suspected (referrals)
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Soft-tissue care
Poor surgery
Up to the closure of the wound the soft tissues
must be handled with greatest care
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Management of Infection

• Conventional or Classical Approach
• Modern Approach

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Antibiotic cement Introduction

• 1970 Buchholz and Engelbrecht
• 1972 Buchholz and Gartmann
• HIPS
• Klemm
• Beads

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Antibiotic cement Advantages

• Antibiotic Elution
• Independent of Vascularity
• Patient Compliance
• Toxicity
• Cost
• Dead Space
• Mechanical Support

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Procedure

• Tract Excision
• Removal of Loose Implant
• Reaming of the Canal

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ROD Preparation
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ROD Insertion
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Experience

• 16 Patients
• 8 Femur
• 7 Tibia
• 1 Humerus
• 18-54 years (38.5)

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Bacterial Isolates

• Culture No of patients
• Staphaureus 5
• Enterobacter 3
• Sterile 8

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Case Profile Index Surgery

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• ILN Plating Ex fixator
• Femur 5 - 3
• Tibia 3 2 2
• Humerus - 1 -

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Rod Fabrication

• K Nail 11
• Steel Wire 4
• ILN 1

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Infection Control

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• ILN Plating Ex fixator
• Femur 4 - 1
• Tibia 3 1 1
• Humerus- 1 -
• 5 patients had draining wounds
• 3 serous
• 2 purulent with decrease in volume

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Union (Six Months)

• ILN Plating Ex fixator
• Femur 4 - 1
• Tibia 3 - 1
• Humerus - - -

Another TWO case united in 8 months One each of
Humerusand Tibia
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Union

• Bone Grafting after Control of Infection
• One Femur
• One Tibia
• 1 Tibia required External Fixation after control
  of Infection with Bone Grafting

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Failures

• 1 case-infection controlled nonunion - ex fix
• 1 had infected non union - ex fix
• Femur managed primarily with Ex Fix - bad results

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Conclusions
Relatively New Procedure Standardisation Good
Control of Infection Toxicity Cost Dead
Space Mechanical Support ? Small Sample ---More
Studies
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Representative case-1
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Presentative Case-2
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Representative Case-3
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Case-4