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Infected Tibial Non Unions

- See: tibial fracture menu and infection menu

- Discussion:
    - by definition involves a tibia fracture infection that has gone on to non union;
    - by definition, infected non union is a Cierney IV osteomyelitis, meaning that the fracture is
            unstable before and after the debridement;
    - infected non union is a relative contraindication to internal fixation across the frx;
    - tibial nonunions should never be approached thru a previously infected scar; 
          - instead plan lateral or posterior approaches, avoiding as much as possible the ends of long bones,
                   & roughening normal parts of bone;
          - large iliac grafts may be placed between the tibia and fibula 
    - reference:
          - Infected nonunion of the long bones.

- Work Up: 
    - an infected delayed union requires débridement, soft-tissue coverage, bone stabilization and bone-grafting; 
    - radiographs:
          - attempt to determine from x-rays, how much bone needs to be debrided;
          - plan for hardware removal; 
    - bone scan: indium scan: may offer higher specificity;
    - CBC, sed rate, CRP;
    - reference: 
          - Diagnosis of infection in ununited fractures. Combined imaging with indium-111-labeled leukocytes and technetium-99m methylene diphosphonate.

- Initial Management:
    - debridement of sequestrum
          - the most important element in debridement to remove a sequestrum and other devitalized tissue;
          - in some cases there may be an obvious sequestrum with an associated draining sinus;
                  - consider making small anterolateral incision (over anterior compartment) inorder to reach
                              and debride sequestrum, and consider reaming the IM canal inorder to debride the
                              rest of the canal;
                  - following the osseous debridement, the skin drainage will often resolve, thus preventing the need
                              for soft tissue coverage;
                  - consider need for antibiotic bead application; 
    - hardware: controversies:
          - references:
                  - Treatment of infection after fracture fixation. Opinion: two-stage protocol: treatment of nonunion after treatment of infection.
                  - Treatment of infection after fracture fixation. Opinion: retain stable implant and suppress infection until union.
    - soft tissue coverage
    - see contaminated wound care and wound vac);
          - preoperatively, determine whether there will be a need for extensive soft tissue debridement;
                  - excision of draining sinuses, ect), which might in some cases require application of a free flap;
                  - note that following debridement of sequestrum, the draining sinus will often spontaneously resolve;
          - references:
                  - Closure of the skin defect overlying infected non-union by skin traction.

- Tibial Stabilization: 
    - intramedullary nailing:
          - references:
                - Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects.  
                - Treatment of infected pseudarthrosis of the femur and tibia with an interlocking nail.
                - Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails
    - circular wire fixators:
          - a simple hybid fixator can be applied, if the goal is to merely obtain bony union;
          - if there has been tibial shortening (from frx debridement), then limb lengthening can be considered once there is frx union;
    - ilizarov technique:
          - this statedegy involves potential for simultaneous compression of the frx site along with lengthening of the opposite metaphysis
                     (to compensate for the shortening brought about from debridement);
          - when Ilizarov is used in conjunction w/ radical resection and distraction histiogenesis, the majority of patients can expect at
                     least one minor complication;
         - bone union averages 6 months once intercalary segments come into contact; 
         - reference:
                - Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection

- Fracture Healing and Restoration of Length:  (see managment of tibia fracture defects)
    - tibial lengthening
    - bone morphogenic proteins
    - posterolateral bone grafting:
          - can be used to avoid significant shortening; 
          - whenever possible, posterolat. graft via virgin approach is used to avoid subjecting previously traumatized area to more insult;
          - has been successful in treating infected non-unions & can be performed w/o disturbing anteromedial soft tissue defects; 
          - contraindicated a fibulectomy has been performed previously; 
    - induced membrane technique

    - papineau technique
    - references:    
          - Results of bone grafting for infected tibial nonunion.
          - Treatment of infected non-unions and segmental defects of the tibia with staged microvascular muscle transplantation and bone-grafting

Non-vascularised fibular transfer in the management of defects of long bones after sequestrectomy in children.

The infected nonunion of the tibia.

Treatment of sequestra, pseudarthroses, and defects in the long bones of children who have chronic hematogenous osteomyelitis

Results of vancomycin-impregnated cancellous bone grafting for infected tibial nonunion.

Infected nonunion of the long bones.

Nonunion of the diaphysis of long bones.

Management of infected nonunion of long bones: The last decade (1996-2006).