Date: Wed, 5 Jul 2000 22:28:11 +0600

Subject: ? Infected Femur Fx

Hello all,

I offer a case that might be interesting to the group. A male patient 36 y.o, 10 month prior to this admission sustained a femoral shaft fracture treated in another facility initially by nailing (of unknown type), than after a couple of months it was replaced by a plate (don't know why). After a month or so after the second surgery drainage appeared. The plate was removed, a plaster cast applied. Wound and drainage sinus closed within 3-4 weeks after plate removal. He was in the cast (3 months), then started knee motions (90 degrees reached) and partial weight-bearing. A couple of weeks before this admission he started full weitht-bearing. The femur cracked without any trauma, while normal walking. What could be treatment plan for the patient?

Best regards, Alexander N. Chelnokov, Ural Scientific Institute of Traumatology and Orthopaedics, str.Bankovsky, 7. Ekaterinburg 620014 Russia



Reply at: Orthopaedic Trauma Association forum

Date: Wed, 5 Jul 2000 14:39:53 -0400

From: bruce meinhard

The upper fracture is a hypertrophic non union and the lower seems atrophic. I would like to assess the presence of infection before surgery. A cbc and diff, esr, and crp would be helpful. Some would add an Indium111l white cell scan. If the infection was quiescent, a biopsy at two fracture sites, done percutaneously with a needle for culture of tissue, would be most helpful to rule out infection. If infection is absent, reamed IM rod would work well.

If fear of activation of quiescent infection or if the infection were active an ExFix with monofocal compression at the upper fracture site and proximal bone transport at the distal fracture could correct leg length at the same time as union is promoted (via Ilizarov) would work also.

BPM


Date: Wed, 05 Jul 2000 14:28:53 -0500

From: Adam Starr

Hi Alex.

I would bet he's still infected. I would explore his old wound, obtain cultures and tissue samples, debride any infected soft tissues and infected bone (a CT might be helpful in finding an involucrum - can't tell if there is one one your film) and then I would stabilize his fractures with a reamed, statically locked nail.

If there was gross pus at the time of the I & D, then I would repeat I & D every 48 hours untill there was no more pus, no more dead tissue. Then I would place antibiotic beads, put him in traction on IV antibiotics, and remove the beads in 2 weeks. At the time of bead removal, if the wound was clean, I would nail him. If there wound still had pus in it, I would re-place the beads.

A femur that is stabilized with a nail will often go on to unite even in the presence of infection. I would give him IV antibiotic for 6 weeks for osteomyelitis.

Once his femur healed, you could debate whether or not to remove the nail. If you DID remove it, I would ream the canal and put a Gigli saw with antibiotic beads stuck to it down into the canal. I would remove the saw in 2 weeks.

Good luck.

Adam Starr, Dallas, Texas


Date: Wed, 05 Jul 2000 15:30:14 -0500

From: Steven Rabin

hello.

he's got an infected malunion/nonunion. The distal fracture site is atrophic in appearance - from the x-ray i can't tell if it was part of the original fracture or a new fracture perhaps through an old screw hole. The proximal fracture is mal-aligned but hypertrophic. Even if its not infected, its significantly mal-aligned and needs to be straightened for appropriate alignment mechanics.

treatment requires a definite diagnosis, restoration of biology, and restoration of mechanics. The diagnosis requires aerobic/anaerobic cultures including tissue cultures. Basic blood work including CBC, diff, and sed rate. Also, more specific history if possible - what kind of a host is he? at 36 years old, i assume he is a good host, but does he smoke? diabetic? what do the soft tissues look like? (are they scarred down and rigid or flexible?) are there any other local or systemic factors that might influence healing?

To restore biology, he needs an aggressive irrigation and debridement. Everything that looks even remotely necrotic, infected, or nonviable needs to be removed. I would also ream the medulllary canal to remove any granulation material or infected debris since he did originally have a rodding procedure and the medullary canal may still be contaminated.

To restore mechanics, he needs improved alignment and stability. Ideally i would try to achieve both with an osteotomy of the proximal fracture and a repeat antegrade intramedullary nailing. (Retrograde rodding obviously risks septic arthritis of the knee.) Clinical judgement would be important here. If the bone looks healthy (is a nice white color, not brittle, has punctate bleeding with intact perisoteum) - then i would just go with a large diameter rod filling the canal. If the bone looked doubtful (yellowish color, brittle, avascular), then i would remove all the doubtful bone and perform an Ilizarov type bone transport with an unilateral frame over an antegrade rod, but would use a smaller diameter rod to allow room for the pins of the fixator. In some of these cases, i debride and temporarily ext fix and then come back for a second look repeat debridement especially if my debridement has created dead space - then i place antibiotic impreganted beads at the first debridement and remove them at the second.

Getting back to restroring biology: Usually a muscle flap is not necessary for a femur nonunion, but if the soft tissues are stiff and edematous, it might be necessary to eliminate dead space and bring in healthy tissue. If i do not remove a segmental piece of bone, but do just the rodding, i also consider bone grafting at a later date (6-12weeks), especially if the soft tissues especially periosteum has been damaged. I have also supplemented with internal or external electrical stimulation, and ultrasound may also be helpful.

In summary, you need to restore mechanical stability and healthy soft tissues to the fracture site while eliminating dead or infecxted bone to achieve a successful union. Follow Cierny's principles.


Date: Wed, 5 Jul 2000 19:47:59 -0500

From: Gregory J Schmeling

I am confused. This appears to be a hypertrophic malunion/nonunion with a new fracture, probably at one of the screw sites from the plate. I cannot make the leap of faith that this is an atrophic nonunion without old xrays. The femur could have failed through an old screw hole with normal walking. Even so, I would start with a bone / WBC scan to identify active infection. If you do not have access to that then I would do an open debridement of both sites individually and culture each site at least three times (no good reason for the number of cultures). If the cultures are all negative I would take down the malunion/nonunion, re-align the anatomy and place a reamed nail (preferably one that can be dynamically locked). I would cover him with antibiotics for 48 hours (longer if he is systemically compromised (Cierney, et al)). If the cultures were positive, I would re-debride all dead bone, take down and correct the alignment of the bone, place culture specific local antibiotics, and give him culture specific systemic antibiotics (especially if he is smoker, diabetic, etc.). At two weeks or so ( for no good reason ), if the wounds all looked good, I would then nail the femur (static) and continue the antibiotics for 4 more weeks. Good Luck!

Greg Schmeling


Date: Thu, 6 Jul 2000 19:39:52 +0600

From: Alexander Chelnokov

Hello bruce,

bm> The upper fracture is a hypertrophic non union

Very likely. Though it was stiff enough to allow weight-bearing.

bm> and the lower seems atrophic.

No, it looks like stress fracture through a screw hole.

bm> I would like to assess the presence of infection before surgery.

As i told, there was no drainage for more than 3 months. And i should add that there was apparently no local sign of infection as well as in laboratory data.

bm> helpful to rule out infection. If infection is absent, reamed IM rod would work well.

Do you mean open alignment at the level of hypertrophic nonunion?

bm>If fear of activation of quiescent infection or if the infection were active an ExFix with monofocal compression at the upper frecture site

How about the varus?

bm> and proximal bone transport at the distal fracture could correct leg length at the same time as union is promoted (via Ilizarov)

It looks like there is no bone defect and all length inequality is because of varus at upper level. So what is the use of bone transport here?

Best regards, Alexander N. Chelnokov, Ural Scientific Institute of Traumatology and Orthopaedics, str.Bankovsky, 7. Ekaterinburg 620014 Russia


Date: Thu, 06 Jul 2000 09:05:38 -0500

From: Adam Starr

I would do my best to avoid ring fixators or ex-fix in this case. If there is no sign of active infection, and no sign of infection after wound exploration, then I'm even more in favor of an IM nail.

I would try to correct the mal-alignment at the nonunion site closed. I bet you could bend it once the patient was asleep and paralyzed.

If that didn't work, then an osteotomy should do it. I don't think perfect cortical abutment is necessary - simply get the alignment in an acceptable position.

I don't think you need bone transport. I sure hope you don't need a flap.

Adam Starr, Dallas, Texas


Date: Fri, 7 Jul 2000 00:56:52 +0600

From: Alexander Chelnokov

Hello Adam,

AS> I would do my best to avoid ring fixators or ex-fix in this case.

Why?

AS> after wound exploration, then I'm even more in favor of an IM nail.

We have no practical experience with modern nails.

AS> I would try to correct the mal-alignment at the nonunion site closed. I bet you could bend it once the patient was asleep and paralyzed.

;-/ I am doubtful on this. Some of us are sure that only osteotomy can mobilize the site.

AS> If that didn't work, then an osteotomy should do it. I don't think perfect cortical abutment is necessary - simply get the alignment

I agree.

AS> I don't think you need bone transport. I sure hope you don't need a flap.

Agree too. So if i had the mentioned equipment i would try to manage the case like you offered.

Best regards, Alexander N. Chelnokov, Ural Scientific Institute of Traumatology and Orthopaedics, str.Bankovsky, 7. Ekaterinburg 620014 Russia


Date: Thu, 6 Jul 2000 16:03:57 -0400

From: bruce meinhard

Correct the Varus with corticotomy if you rod or use the ex fix method. the ex fix method allows treatment changes along the way if an inequality of length is present, you haven't burned any bridges if the latter method is used. the rod can be inserted open or closed with X-Ray condrol.

lastly, monofocal compression would aid the upper fracture to heal provided the varus is first corrected.

bpm


Date: Thu, 06 Jul 2000 15:17:00 -0500

From: Adam Starr

Hi Alex,

AS> I would do my best to avoid ring fixators or ex-fix in this case.

AC> Why?

Because the results with IM nailing are so much better.

AS> I would try to correct the mal-alignment at the nonunion site closed. I bet you could bend it once the patient was asleep and paralyzed.

AC> ;-/ I am doubtful on this. Some of us are sure that only osteotomy can mobilize the site.

I have had some luck manipulating femoral nonunions, so if I was going to do this case, I would discuss that option with the patient. If I can bend it closed, great. If not, then I would perform an osteotomy through a small incision.