Need for two or more debridements.
VIII. Complications
A. Recurrence of infection following successful bony healing requires removal of hardware, debridement, and treatment with antibiotics.
B. Infected nonunion
1. Removal of hardware, aggressive debridement.
2. Culture-directed antibiotic treatment for 6 weeks.
3. Repeat open reduction and internal fixation versus external fixation.
C. Septic arthritis.
D. Osteomyelitis.
E. Amputation.
IX. Special Considerations—Pediatric Population
A. Concern for septic arthritis due to bacterial seeding.
B. Inability to ambulate with a remote history of trauma may suggest infection.
Conclusion
Infection after internal fixation of fractures is one of the most common complications. Infections significantly increase the cost and the morbidity of an injury. By following standardized diagnosis and treatment regimens outcomes can be optimized. Surgeons need to assure diagnosis of infection, optimize the patient by improving host factors as much as possible and utilizing a multidisciplinary team. A thorough operative debridement of all necrotic and infected tissue is critical. The surgeon then needs to decide to retain or remove implants with a immediate or staged revision fixation. Antibiotics should be culture driven if possible and can be administered intravenous or by oral methods. Adequate soft tissue coverage may require a rotational or free flap. Without a standardized process and multidisciplinary team patients are at risk for persistent infection and/or amputation.
Suggested Readings
Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA, Bosse M; Southeast Fracture Consortium. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am 2010;92(4):823–828
Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350(14):1422–1429
Lawrenz JM, Frangiamore SJ, Rane AA, Cantrell WA, Vallier HA. Treatment approach for infection of healed fractures after internal fixation. J Orthop Trauma 2017;31(11):e358–e363
Meehan AM, Osmon DR, Duffy MC, Hanssen AD, Keating MR. Outcome of penicillin-susceptible streptococcal prosthetic joint infection treated with debridement and retention of the prosthesis. Clin Infect Dis 2003;36(7):845–849
Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair: management with hardware in place. Clin Orthop Relat Res 2008;466(2):466–472
Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg Am 2013;95(15):1409–1412
Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. J Bone Joint Surg Br 2005;87(2):249–256
Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE; Foreign-Body Infection (FBI) Study Group. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. JAMA 1998;279(19):1537–1541
7 Nonunion and Malunion
David B. Weiss and Michael M. Hadeed
Introduction
The goal of orthopaedic fracture care is to treat fractures in a way that minimizes complications while maximizing functional outcomes. This includes both operative and nonoperative management.
Bone healing is typically robust and dependable; however, it can fail. When it does, it can result in a nonunion or a malunion. It is critical to understand both the natural history and effect of interventions on bone healing as operative indications are often based on the ability to decrease the chance of nonunion and malunion.
When a patient develops a nonunion or a malunion, the cost to the health care system and society is great, as it typically results in multiple surgical procedures and extended time away from normal activities. A tibial nonunion has been compared to having an effect on health and wellbeing similar to some cancer or other chronic illness diagnoses.
To understand malunions and nonunions, it is critical to have a basic understanding of bone healing and the biomechanics of fracture repair (discussed in depth in Chapter 1, Physiology of Fracture Healing, and Chapter 4, Biomechanics of Internal Fracture Fixation). When approaching these difficult cases, it is important to have a stepwise, reproducible approach, make the diagnosis using the history, physical exam, laboratory and radiographic data. Try to determine the causative factor. Based on patient-specific variables, develop a treatment plan with a reasonable chance of success (▶Video 7.1).
Keywords: nonunion, malunion, hypertrophic, atrophic, bone graft
I. Assessment of Nonunions
Factors leading to nonunion can generally be grouped into two categories: biologic and mechanical. The assessment is a gathering of data on known factors which may have contributed to a failure of the biologic and mechanical success of the fracture healing.
A. History
1. Common presenting symptoms:
a. Pain at the fracture site (increased with weightbearing).
b. Subjective feelings of instability in the affected bone.
c. Symptoms (or history of symptoms) associated with infection: erythema, swelling, drainage, fevers, chills.
2. The data of patient-specific risk factors is obtained after completing a thorough history with each individual patient.
a. Demographic/patient directed risk factors:
i. Smoking has negative effects on many pathways necessary for bone healing.
ii. Nicotine diminishes arterial blood flow.
iii. Nonsteroidal anti-inflammatory drugs negatively affect the pathways responsible for bone healing.
iv. In some studies, female patients and older patients had an increased rate of nonunion.
v. Poor nutrition is associated with nonunion.
b. Associated comorbidities:
i. Metabolic and endocrine dysfunction can impair fracture healing.
ii. Diseases that negatively affect
