PMID: 15289697

Issn Print: 0890-5339

Publication Date: 2004/08/01


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OPINION: Open Reduction and Internal Fixation and Resection Tricortical Bone Grafting

Joseph Borrelli

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Excerpt

This case represents a not too uncommon scenario in which open fracture of a long bone, in this case the ulna, goes on to develop into an infected nonunion. The diagnosis of a deep infection and/or osteomyelitis can typically be suspected based upon clinical findings. Important information in making such a diagnosis includes a thorough understanding of the history and nature of the fracture, the patient’s current symptoms, and current physical findings. In the absence of a draining sinus, palpable abscess, or erythema, pain and swelling at the fracture site should raise the surgeon’s suspicions as to the possibility of a deep infection. Routine laboratory studies including a white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and a Creactive protein (CRP) may assist in the diagnosis, but because of their relatively poor sensitivity are better negative predictors of infection. Although plain radiographs may also assist in the diagnosis, particularly if progressive implant loosening, bone loss, and periosteal reaction are seen, they too are not diagnostic of infection. Other imaging studies including Tc-99 bone scan, Indium nuclear scans, computed tomography (CT), and magnetic resonance imaging (MRI) are only marginally helpful in the face of a previously surgically treated fracture. Of course, definitive diagnosis can be made by obtaining material from the site either via aspiration or biopsy and identifying bacteria within. Once diagnosed, the type of infected nonunion should be classified according to Cierny et al to aid in the treatment and prognosis. 1 According to this classification system, this infected nonunion would be classified as a type IIIA (localized osteomyelitis in a good host).
Initial treatment of infected non-unions with loose or ineffective implants includes debridement of the devitalized and infected material (soft tissues and bone), irrigation, and stabilization. Bone defects can be filled with antibiotic impregnated polymethyl methacrylate (PMMA) to bring high concentrations of antibiotics into the area while maintaining length and space for future reconstruction. 2,3
In this case, a thorough debridement of the infected nonunion was performed, leaving a 2-cm ulnar defect, which was temporarily filled with antibiotic impregnated PMMA. A circular external fixator was applied for subsequent bone transport but could have just as easily been stabilized with a 4-pin uniplanar small external fixator. A course of intravenous antibiotics was initiated with the type and duration of antibiotics dependent upon the bacteria isolated, classification of the infected nonunion, and the quality of the host. Confirmation that the infection has been eradicated can be made with some degree of certainty based upon repeat physical examination and laboratory tests (ESR, CRP). A culture negative biopsy of the area, taken after antibiotics have been discontinued at least 5 to 7 days, will add further support that the infection has been eradicated. At this time, definitive reconstruction of the ulna can be performed.
Several options exist for reconstruction of a 2-cm diaphyseal defect in a long bone. These options include bone transport, open reduction and internal fixation (ORIF) with a vascularized bone graft, ORIF with morselized cancellous bone graft, and ORIF with strut graft. Several recent publications have described the successful use of ORIF with strut grafting from the iliac crest for defects of the radius and ulna. 4 The advantages of this procedure over the others include the structural nature of the bone graft, reliable healing of the graft ends, and specialized surgical skills (vascular anastomosis) are not necessary. This technique has evolved over the last 60 years to its current point. 4–13 The recipient site is prepared by removing the PMMA space, debriding the fibrotic tissue, and freshening the bone ends.

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