Date: Mon, 29 Apr 2002 18:23:32 +0600
Subject: Gunshot fracture of the femur
Hello All,
A male 25 y.o 3 months ago was fixed by the Ilizarov fixator applied somewhere else for comminuted femoral fracture after low velocity shotgun wound. Wound healed without infection. Knee ROM is only 20 degrees to date. Recent xrays attached. I think about conversion to an intramedullary nail at least to improve knee function.
Pin sites and the femur in general show no signs of infection. L- 5,1x10^9/l, ESR - 27 mm/hr. But 2 weeks ago he reported episode of hyperthermia 39 degrees and pain in the femur. After 2-3 days all signs disappeared with 5 days of i/m cefalexin.
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Is now the surgey rational? What additional tests should be performed if any? Should the fixator be removed on the table or prior (how long?) the surgery? What anibiotic is optimal without any confirmed infection agent and for what period before and after the surgery?
THX in advance.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 29 Apr 2002 10:41:16 -0400
From: James Carr
I would be nervous re: intramedullary sepsis. I guess you could remove the fixator under genl anesthesia, currette/culture, and treat with antibiotics appropriately. The nail at some point when things quiet down. I don't plate many femoral shafts, but I would consider a bridge plating along with muscle release. You could even go sub-q with the LISS system. I know that ex-fix followed by plating has been a good option in the tibia, and has not led to high infection rates- something that can't be said with IM nailing after ex-fix.
JBC
Date: Mon, 29 Apr 2002 11:29:00 -0400
From: J. Tracy Watson
We have looked at this problem of Ilizarov removal followed by secondary
procedures...immediate exchange to IM nail had the HIGHEST rate of infection
even if the pin sites were pristine at time of secondary procedure...8
patients were treated in this fashion....7 got infected.(88%) infected
nails...don't do this...
For the remainder of the series 42 patients were
all staged...i.e. frames removed and pin sites curretted and irrigated...post
debridement cultures taken and deep culture specific antibiotics given if
culture +. Secondary procedures then followed once the pin tracts had
completely healed. Secondary Plating or IM nailing was very successful.
However, if the latency period was greater than one month..i.e. Ilizarov
removal, pin irrigation, pin sites healed at one month THEN secondary
procedure...no infections...If the latency period was LESS than one month
even with culture negative pin tracts... still 35% infection....
If you can
temporize the patient out of the frame - even if it requires traction....then
remove frame, I and D the pin sites with post debridement DEEP
cultures....treat if necessary , let pin sites declare and heal
themselves...THEN secondary IM nailing or plating after 1 month latency
period. If pin sites never heal completely or if you culture some horrific
resistant bug ....then consider extramedullary implant..or back to an
ex-fix
J. Tracy Watson / Djoldas Kuldjanov
Date: Mon, 29 Apr 2002 12:30
From: Bill Burman
With respect to IM nail exchange for ex-fix consider the paper
presented by Rubel et al from the OTA 2001 San Diego Annual Mtg and
then re-read at AAOS Dallas 2002 as a highlight paper (considered one of
the best scientific papers of the OTA 2001 Annual Meeting) Basically the protocol was much the same as that suggested by Drs. Watson
and Kuldjanov except that they added the requirement of a negative pre-nailing
pin-tract biopsy. Date: Mon, 29 Apr 2002 19:16:37 +0100
From: Nuno Craveiro Lopes
Alexander,
As the safest way (infection and non union less probable), I would consider
atrophic pseudarthrosis resection, acute compression and proximal
lengthening with Ilizarov frame for this case.
Later it will be necessary a quadriceplasty.
Best regards,
Nuno Craveiro Lopes
Date: Thu, 2 May 2002 02:10:55 +0600
From: Alexander Chelnokov
Hello J.,
JTW> procedures...immediate exchange to IM nail had the HIGHEST rate of
infection even if the pin sites were pristine at time of secondary proceedure...8
patients were treated in this fashion....7 got infected.(88%) infected
What sort of nailing was performed in these cases? Were nails solid or
cannulated? Reamed or unreamed? What kind of infection was occured?
When? What measures it required and what it was resulted with?
All our femoral exchanges were either before 3 weeks since ex-fix
application or unintenionally later than 1 month after fixator removal.
But recent months i performed 4 similar ex-fix to IM nail exchanges in
tibial fractures, and two of them (with prior fixation 2 and 4 months)
were done immediately on the table, and pins/wires were being removed
one by one while nail was inserted. In two other cases (2 and 11
months of prior exernal fixation) fixator was removed 5 and 10 days
before the surgery because of some drainage (not pus clinically) from
pin sites. Unreamed solid nails (UTN) were used in all cases. All 4
proceed to uneventful healing with 4-5 days of oral ciprofloxacin. Now
i think either it was incredible luck, or staphyllococci at your side
are much more angry, if also solid unreamed nails were used.
Any suggestions? THX in advance.
Best regards,
Alexander N. Chelnokov
Date: Sat, 4 May 2002 17:00:05 +0600
From: Alexander Chelnokov
Hello Bill,
BB> Basically the protocol was much the same as that suggested by Drs. Watson
and Kuldjanov except that they added the requirement of a negative
pre-nailing pin-tract biopsy.
This paper is about exchange nailing for ex-fix with
confirmed multifocal osteomyelitis of pin sites.
In the discussed case no one wire/pin shows signs of infection after 3
months of fixation. So hardly ever so rigorous protocol was necessary
for the case.
Best regards,
Alexander N. Chelnokov
Date: Sat, 4 May 2002 12:00
From: Bill Burman
In the discussed case no one wire/pin shows signs of infection after 3
months of fixation. So hardly ever so rigorous protocol was necessary for the case.
Alex
Watson and Kuldjanov said they had an 88% infection rate with late, non-staged
exfix-IM nail exchanges - even with *pristine* pin sites.
With confirmed osteomyelitis of the pin sites, Rubel et al had no infections
with late exfix-IM nail exchanges if staged pre-nailing pin-tract biopsies were
negative.
In four cases you discussed 5/2/2002, there was apparent avoidance of
infection with late exfix-IM nail exchanges (2 non-staged, 2 staged) treated with
4-5 days of oral ciprofloxacin.
You wrote:
"Now i think either it was incredible luck, or staphyllococci at your side are
much more angry, if also solid unreamed nails were used. "
The question I am trying to raise is that if there is any doubt as to the
possibility of pin tract colonization, why not take the added precaution of
staged pre-nailing pin tract biopsies?
Date: Sun, 5 May 2002 00:45:00 +0600
From: Alexander Chelnokov
Hello Bill,
BB> Watson and Kuldjanov said they had an 88% infection rate with late,
non-staged exfix-IM nail exchanges - even with *pristine* pin sites.
Don't you know what nails were used in their series - solid or hollow?
BB> possibility of pin tract colinization, why not take the added precaution of
staged pre-nailing pin tract biopsies?
Do you mean to take a culture with fixator in place? Or you ask why
not operate after a period of time to allow pin sites to heal? I
wouldn't trust too much our bacteriology reports.
In view of so discouraging infection rates as reported Dr Watson for
the non-staged group definitely the lag period is necessary.
The only problem is what to do with the leg (and patient) after
external device removal before nailing. If the patient has been mobile
recent weeks, he would not be too enthusiastic about bed traction.
Maybe it is worth to insert new pins/wires prior to remove the old
ones, to keep external fixator in place and allow the level of
activity?
Our modest exchange experience was more optimistic so i proceed with
the nailing (UFN 11 mm) before i read answers :-(
So 5th day i am about a nervous breakdown. After the surgery except
the cold shower from the group a laboratory report was received that
he is also HIV and hep. C infected. So i keep fingers crossed. I
attached xrays and current view of the leg. All looks calm at the
moment... How long to proceed with antibiotics and heparin?
Almada, Portugal
http://clientes.netvisao.pt/nfrancac/
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
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The patient feels fine, no fever, ambulates with crutches, knee ROM is 0/90, and he is going to leave for home tomorrow.
Comments and moral support are welcome... THX in advance.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sat, 4 May 2002 19:00:54 EDT
From: Tadabq
Alex
I'm happy to provide moral support. I know for a fact that it is possible to obtain good healing with an intramedullary nail after external fixation as I've seen dozens of successful cases. So in this instance you should watch and wait and if this patient has a problem with infection then treat it. If he doesn't, great for everyone. Intramedullary nailing is fundamentally an excellent technique (mechanically and physiologically) and will overcome many (but not all) technical and situational problems.
That doesn't mean that you should keep nailing them until you experience an unacceptable infection rate. Especially with HIV + etc.
TD
Date: Sat, 4 May 2002 19:36:11 -0400
From: Manuel Sotelo
Meaning that you don't nail a HIV+?
Regards
Manuel
Date: Sun, 5 May 2002 13:16:11 EDT
From: Tadabq
Meaning I expect a significant infection rate if performing IM nail after XF and I expect it would be even higher with IM nail after XF in cases with HIV + and would seek out alternative treatments with lower or more acceptable infection rates.
TD
Date: Sun, 5 May 2002 09:50:56 +0600
From: Alexander Chelnokov
Hello Tom,
Tac> I'm happy to provide moral support.
THX for the support! :-)
Tac> That doesn't mean that you should keep nailing them until you experience an unacceptable infection rate. Especially with HIV + etc.
Certainly. According to your experience does nail design (solid or hollow) and technique (reamed/unreamed) influence infection rate in similar cases?
THX again.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sun, 5 May 2002 07:57:41 +0530
From: DR T I GEORGE
I feel that there may be some point in Alex's statement though yet to be proved scientifically.
"Now i think either it was incredible luck, or staphyllococci at your side are much more angry, if also solid unreamed nails were used. "
From what I know during the original work of Ilizarov the role of antibiotics was minimal which is not the case in my experience. Of course HIV was unknown in those days. May be this is a food for thought and some work in future- to do an intercontinental study on the virulence of the same organism.(I am unaware of such a study if already published).
DR T I GEORGE,
Consultant Orthopaedic surgeon
Polytrauma, Microvascular Surgery and Hand Surgery Unit
Metropolitan Hospital, Trichur, South India