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Current treatment of infected non-union after intramedullary nailingSimpson AHRW* and Tsang STJDepartment of Trauma and Orthopaedics,University of EdinburghRoyal Infirmary of Edinburgh51 Little France CrescentOld Dalkeith RoadEdinburghEH16 4SA*Corresponding authorProfessor Hamish SimpsonDepartment of Trauma and Orthopaedics,University of EdinburghRoyal Infirmary of Edinburgh51 Little France CrescentOld Dalkeith RoadEdinburghEH16 4SA0131 2426649Hamish. Simpson@ed.ac.ukAbstractNonunion is a devastating consequence of a fracture. Nonunions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of nonunion following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.Word count 157IntroductionNonunion is a devastating consequence of a fracture. Nonunions cause substantial patient morbidityADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s11999-009-0883-x", "ISSN" : "0009-921X", "author" : [ { "dropping-particle" : "", "family" : "Egol", "given" : "K A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gruson", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spitzer", "given" : "A B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Walsh", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tejwani", "given" : "N C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical Orthopaedics and Related Research", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2009" ] ] }, "note" : "Times Cited: 0\nEgol, Kenneth A. Gruson, Konrad Spitzer, Allison B. Walsh, Michael Tejwani, Nirmal C.\n0", "page" : "2979-2985", "title" : "Do Successful Surgical Results after Operative Treatment of Long-bone Nonunions Correlate with Outcomes?", "type" : "article-journal", "volume" : "467" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[1]", "plainTextFormattedCitation" : "[1]", "previouslyFormattedCitation" : "[1]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[1] with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of lifeADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "14765871", "abstract" : "There are few reports on function after limb salvage surgery using the Ilizarov technique, and none that document the pattern of recovery or predict when maximum function returns. This prospective, longitudinal study documents the baseline functional abilities of 40 consecutive patients with nonunion of a fracture in the lower limb. Patients were studied for at least two and a half years following the completion of surgery. Function was measured by timed tests of functional performance and by the Toronto Extremity Salvage Score self-reported patient questionnaire. Recovery was slowest in the early stages after removal of the frame and greatest between six months and one year. Statistically significant improvement continued up to, but not beyond two years. This observation has important implications for the length of follow-up incorporated into the rehabilitation programmes for patients, predictions of patient status in regard to compensation and for the design of future studies to evaluate functional outcome.", "author" : [ { "dropping-particle" : "", "family" : "Barker", "given" : "K L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lamb", "given" : "S E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2004", "1" ] ] }, "page" : "81-5", "title" : "Functional recovery in patients with nonunion treated with the Ilizarov technique.", "type" : "article-journal", "volume" : "86" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[2]", "plainTextFormattedCitation" : "[2]", "previouslyFormattedCitation" : "[2]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[2]. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. Nonunions are expensive to manage, with estimates of treatment costs ranging from ?7,000 to ?79,000 ($10,000-$114,000) per caseADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/s0020-1383(08)70019-6", "ISSN" : "0020-1383", "author" : [ { "dropping-particle" : "", "family" : "Kanakaris", "given" : "N K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Calori", "given" : "G M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Verdonk", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burssens", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Biase", "given" : "P", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Capanna", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vangosa", "given" : "L B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cherubino", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baldo", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ristiniemi", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kontakis", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury-International Journal of the Care of the Injured", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "note" : "Times Cited: 39\nKanakaris, Nikolaos K. Calori, Giorgio M. Verdonk, Rene Burssens, Peter De Biase, Pietro Capanna, Rodolfo Vangosa, Luca Briatico Cherubino, Paolo Baldo, Franco Ristiniemi, Jukka Kontakis, George Giannoudis, Peter V.\n5th European Symposium on Tissue Engineering Bone Biology Congress\nSep 04, 2008-aug 06, 2009\nBerlin, GERMANY\n39\n2", "page" : "S83-S90", "title" : "Application of BMP-7 to tibial non-unions: A 3-year multicenter experience", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/0301-620x.88b7.17639", "ISSN" : "0301-620X", "abstract" : "We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with llizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully. Using the Association for the Study and Application of the Methods of llizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately 30 pound 000 per patient. We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.", "author" : [ { "dropping-particle" : "", "family" : "Patil", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Montgomery", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-British Volume", "genre" : "JOUR", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2006" ] ] }, "note" : "Times Cited: 20\n21", "page" : "928-932", "title" : "Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications", "type" : "article-journal", "volume" : "88B" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1007/s00264-008-0709-6", "ISSN" : "0341-2695", "abstract" : "The parameter of health economics in the use of any contemporary medical module plays a dominant role in decision making. A prospective nonrandomised comparative study of the direct medical costs on the first attempt of treating aseptic nonunions of tibial fractures, with either autologous-iliac-crest-bone-graft (ICBG) or bone morphogenetic protein-7 (BMP-7), is presented. Twenty-seven consecutive patients, who were successfully treated for fracture nonunions, were divided into two groups. Group 1 (n = 12) received ICBG and group 2 (n = 15) received BMP-7. All patients healed their nonunions, and the financial analysis presented represents a best-case scenario. Three out of 12 of the ICBG group required revision surgery while just one out of 15 required it in the BMP-7 group. Average hospital stay was 10.66 vs. 8.66 days, time-to-union 6.9 vs. 5.5 months, hospitals costs 2,133.6 pound vs. 1,733.33 pound, and theatre costs were 2,413.3 pound vs. 906.67 pound for the ICBG and BMP-7 groups, respectively. The BMP-7 cost was 3002.2 pound. Fixation-implant was 696.4 pound vs. 592.3 pound, radiology 570 pound vs. 270 pound, outpatient 495.8 pound vs. 223.33 pound, and other costs were 451.6 pound vs. 566.27 pound for the ICBG and BMP-7 groups, respectively. The average cost of treatment with BMP-7 was 6.78% higher (P=0.1) than with ICBG, and most of this (41.1%) was related to the actual price of the BMP-7. In addition to the satisfactory efficacy and safety of BMP-7 in comparison to the gold standard of ICBG, as documented in multiple studies, its cost effectiveness is advocated favourably in this analysis.", "author" : [ { "dropping-particle" : "", "family" : "Dahabreh", "given" : "Z", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Calori", "given" : "G M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kanakaris", "given" : "N K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nikolaou", "given" : "V S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International Orthopaedics", "genre" : "JOUR", "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "2009" ] ] }, "note" : "Times Cited: 18\n18", "page" : "1407-1414", "title" : "A cost analysis of treatment of tibial fracture nonunion by bone grafting or bone morphogenetic protein-7", "type" : "article-journal", "volume" : "33" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1016/j.injury.2006.08.055", "ISSN" : "0020-1383", "abstract" : "Objective: To compare the cost implications of treatment of persistent fracture non-unions before and after application of recombinant human bone morphogenetic protein-7 (BMP-7). Method: Of 25 fracture non-unions, 9 were treated using BMP-7 alone and 16 using BMP-7 and bone grafting. These patients were prospectively followed up, and the costs incurred were analysed. Results: The mean number of procedures per fracture performed before application of BMP-7 was 4.16, versus 1.2 thereafter. Mean hospital stay and cost of treatment per fracture before receiving BMP-7 were 26.84 days and 13,844.68 pound, versus 7.8 days and 7338.4 pound thereafter. The overall cost of treatment of persistent fracture non-unions with BMP-7 was 47.0% Less than that of the numerous previous unsuccessful treatments (p = 0.001). Conclusions: Treating fracture non-unions is costly, but this could be reduced by early BMP-7 administration when a complex or persistent fracture non-union is present or anticipated. (C) 2006 Elsevier Ltd. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Dahabreh", "given" : "Ziad", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dimitriou", "given" : "Rozalia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury-International Journal of the Care of the Injured", "genre" : "JOUR", "id" : "ITEM-4", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 37\n37", "page" : "371-377", "title" : "Health economics: A cost analysis of treatment of persistent fracture non-unions using bone morphogenetic protein-7", "type" : "article-journal", "volume" : "38" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[3\u20136]", "plainTextFormattedCitation" : "[3\u20136]", "previouslyFormattedCitation" : "[3\u20136]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[3–6]. Approximately 200 long bone nonunion cases per annum occur per million populationADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bmjopen-2012-002276", "ISSN" : "2044-6055", "PMID" : "23396560", "abstract" : "OBJECTIVES: In the UK there are approximately 850 000 new fractures seen each year. Rates of non-union of 5-10% of fractures have been suggested, the cost to the National Health Service of treating non-union has been reported to range between \u00a37000 and \u00a379 000 per person yet there are little actual data available. The objective of this epidemiological study therefore is for the first time to report the rates of fracture non-union.\n\nDESIGN: A cross-sectional epidemiological study.\n\nSETTING: The population of Scotland.\n\nPARTICIPANTS: All patient admissions to hospital in Scotland are coded according to diagnosis. These data are collected by (and were obtained from) Information Services Department Scotland. Those who have been coded for a bone non-union between 2005 and 2010 were included in the study. No patients were excluded. Population data were obtained from the Registrar General for Scotland.\n\nOUTCOME MEASURE: The number of fracture non-unions per 100 000 population of Scotland according to age, sex and anatomical distribution of non-union.\n\nRESULTS: 4895 non-unions were treated as inpatients in Scotland between 2005 and 2010, averaging 979 per year, with an overall incidence of 18.94 per 100 000 population per annum. The distribution according to gender was 57% male and 43% female. The overall peak incidence according to age was between 30 and 40 years. The mean population of Scotland between 2005 and 2010 was 5 169 140 people.\n\nCONCLUSION: Fracture non-union in the population as a whole remains low at less than 20 per 100 000 population and peaks in the fourth decade of life. Further research is required to determine the risk of non-union per fracture according to age/sex/anatomical distribution. .", "author" : [ { "dropping-particle" : "", "family" : "Mills", "given" : "Leanora Anne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A Hamish R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "BMJ open", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "title" : "The relative incidence of fracture non-union in the Scottish population (5.17 million): a 5-year epidemiological study.", "type" : "article-journal", "volume" : "3" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7], indicating an estimated total of 150,000 in Europe each year. The rates of nonunion following intramedullary (IM) nailing vary according to anatomical locationADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Mills", "given" : "LA", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tsang", "given" : "STJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hooper", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keenan", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "AHRW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone & joint research", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2016" ] ] }, "title" : "The multifactorial aetiology of fracture non-union and the importance of searching for latent infection", "type" : "article-journal", "volume" : "In-press" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[8]", "plainTextFormattedCitation" : "[8]", "previouslyFormattedCitation" : "[8]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[8]. The rates of tibia nonunion following IM nailing vary from 0 to 4 %ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Court-Brown", "given" : "CM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "MM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tornetta III", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "title" : "Trauma. Orthopaedic surgery essentials", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[9]", "plainTextFormattedCitation" : "[9]", "previouslyFormattedCitation" : "[9]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[9] for closed fractures and increase to 36% for Gustilo and Anderson grade IIIBADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0022-5282", "PMID" : "6471139", "abstract" : "Between 1976-1979, 87 Type III open fractures (in 75 patients) were treated at the Hennepin County Medical Center. Factors leading to increased morbidity in Type III fractures were: massive soft-tissue damage; compromised vascularity; severe wound contamination; and marked fracture instability. This study demonstrates, because of varied severity and prognosis, that the current designation of Type III open fracture is too inclusive. We recommend, therefore, that Type III open fractures be divided, in order of worsening prognosis, into three subtypes. Type IIIA--Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound. Type IIIB--Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination. Type IIIC--Open fracture associated with arterial injury requiring repair. Wound sepsis in the three subtypes were: Type IIIA, 4%, IIIB, 52%; and IIIC, 42%; while amputation rates were, respectively, 0%, 16%, and 42%. Only two patients developed osteomyelitis, and 12 patients had delayed or nonunions. Five patients died, all as a result of multisystem trauma. The bacterial pathogens in infected open fractures have changed dramatically over the years. In the present series (1976-1979), 77% of infections were due to Gram-negative bacteria, compared with 24% previously (1961-1975). A change of antibiotic therapy from a first-generation cephalosporin alone to a combination of a cephalosporin and an aminoglycoside, or a third-generation cephalosporin, is currently indicated in Type III open fractures.", "author" : [ { "dropping-particle" : "", "family" : "Gustilo", "given" : "R B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mendoza", "given" : "R M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Williams", "given" : "D N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of trauma", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "1984", "8" ] ] }, "page" : "742-6", "title" : "Problems in the management of type III (severe) open fractures: a new classification of type III open fractures.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[10]", "plainTextFormattedCitation" : "[10]", "previouslyFormattedCitation" : "[10]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[10] injuriesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Court-Brown", "given" : "CM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "MM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tornetta III", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "title" : "Trauma. Orthopaedic surgery essentials", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[9]", "plainTextFormattedCitation" : "[9]", "previouslyFormattedCitation" : "[9]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[9]. Reported rates of secondary surgery to achieve union in femoral diaphyseal fractures range from 0 to 14 %, with an average of 2.4%. Even following nailing of open femoral fractures, the rates of non-union are low ranging from 0 to 4.8%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Court-Brown", "given" : "CM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "MM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tornetta III", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "title" : "Trauma. Orthopaedic surgery essentials", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[9]", "plainTextFormattedCitation" : "[9]", "previouslyFormattedCitation" : "[9]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[9]. The nonunion rate in the humerus following IM nail fixation has been found to range from 0-50%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-921X", "PMID" : "9308537", "abstract" : "From 1992 to 1994, 29 middle and 19 distal humeral shaft fractures (39 acute fractures, six nonunions, and three pathologic fractures) in 48 patients were treated by retrograde locked nailing. The first eight acute fractures were treated with Seidel nails, the other 40 fractures with specially designed humeral locked nails. Nails were inserted from the supracondylar (6) or the olecranon fossa (42) entry portal. With a single operation, all acute fractures and nonunions achieved osseous union without serious complications. The average time to union was 8.2 weeks for acute fractures and 14.2 weeks for nonunions. Recovery of shoulder function was complete. Elbow motion was excellent in all but one nonunion that resulted from a Type IIIB open fracture. Two patients with supracondylar entry had apex to posterior angular malunion. One patient with a distal comminuted fracture had varus malunion. Three patients had an iatrogenic bony split, but healing was unaffected. Patients with pathologic fractures maintained satisfactory arm function postoperatively. Given the few complications and good functional recovery seen in this study, retrograde locked nailing appears to be a good alternative treatment in middle and distal humeral shaft fractures. The olecranon fossa approach, with more linearity to the humerus, is preferred. In the authors' experience, humeral locked nails are inserted more easily and are associated with fewer complications than are Seidel nails.", "author" : [ { "dropping-particle" : "", "family" : "Lin", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hou", "given" : "S M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hang", "given" : "Y S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chao", "given" : "E Y", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-1", "issue" : "342", "issued" : { "date-parts" : [ [ "1997", "9" ] ] }, "page" : "147-55", "title" : "Treatment of humeral shaft fractures by retrograde locked nailing.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0009-921X", "PMID" : "10627704", "abstract" : "Treatment results of antegrade locked nailing of acute humeral shaft fractures, including union rate and recovery of shoulder function, have been inconsistent. This led the current authors to hypothesize that implant design and surgical techniques might account for this inconsistency. In the current study, 47 fractures (38 acute; nine pathologic) in 47 patients achieved union with the techniques of closed nailing, short to long segment nailing, and fracture compression. Satisfactory recovery of shoulder function occurred because of minimal surgical trauma, prevention of impingement by the nail or locking screws, and prevention of axillary nerve injury or comminution of the humeral head. Forty-seven patients with 38 acute fractures and nine pathologic fractures were treated with humeral locked nails. Mean followup time was 21.4 months. With a single operation, all 38 acute fractures proceeded to eventual union; the average time to union was 7.8 weeks. Thirty-five patients had excellent or satisfactory recovery of shoulder function. Complications included slipout of the proximal screw, nail breakage, fragment displacement, and transient postoperative radial nerve palsy. All nine patients with pathologic fractures had substantial pain relief and increased arm function after surgery. The current study shows the reliability of antegrade locked nailing for proximal and middle third fractures of the humeral shaft.", "author" : [ { "dropping-particle" : "", "family" : "Lin", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hou", "given" : "S M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-2", "issue" : "365", "issued" : { "date-parts" : [ [ "1999", "8" ] ] }, "page" : "201-10", "title" : "Antegrade locked nailing for humeral shaft fractures.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "0301-620X", "PMID" : "1624516", "abstract" : "We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.", "author" : [ { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bell", "given" : "K M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Court-Brown", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "M M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-3", "issue" : "4", "issued" : { "date-parts" : [ [ "1992", "7" ] ] }, "page" : "558-62", "title" : "Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "ISSN" : "0004-8682", "PMID" : "8639132", "abstract" : "BACKGROUND: The use of intremedullary nails for the management of humeral shaft fractures has been controversial. Recently, the Seidel nail has become available. The purpose of this study was to review our initial experience with the Seidel nail.\n\nMETHODS: A retrospective clinical and radiographic review of 25 consecutive patients treated with Seidel intramedullary humeral nail was performed. The nail was used for non-union in 10 patients, delayed union in four, acute fracture in eight and pathological fracture in three. Eighteen of the 19 survivors were clinically reviewed at an average of 15 months (range 8-15). Pain, function, satisfaction, shoulder power, range of motion and clinical outcome were graded using the UCLA shoulder score.\n\nRESULTS: Pain was present at the shoulder in four patients and at the fracture site in nine. Average shoulder abduction was 99 degrees and nine patients could not abduct the shoulder past 90 degrees. Sixty-six percent of patients reviewed were graded as only fair or poor using the UCLA shoulder score. In three patients rotational control was not achieved with the distal locking device at the time of surgery. Complications included non-union in 10 patients and three intra-operative fractures.\n\nCONCLUSIONS: Non-union was more likely to occur if rotational control was not obtained, or if the patient had the nail inserted for a previous non-union. Use of the Seidel nail frequently leads to shoulder pain and dysfunction. The distal locking device is unreliable and predisposes to non-union. We do not recommend the continued use of the Seidel nail.", "author" : [ { "dropping-particle" : "", "family" : "Bain", "given" : "G I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandow", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Howie", "given" : "D W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Australian and New Zealand journal of surgery", "id" : "ITEM-4", "issue" : "3", "issued" : { "date-parts" : [ [ "1996", "3" ] ] }, "page" : "156-8", "title" : "Treatment of humeral shaft fractures with the Seidel intramedullary nail.", "type" : "article-journal", "volume" : "66" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "DOI" : "10.1371/journal.pone.0082075", "ISSN" : "1932-6203", "PMID" : "24358141", "abstract" : "There is a debate regarding the choice of operative intervention in humeral shaft fractures that require surgical intervention. The choices for operative interventions include intramedullary nailing (IMN) and dynamic compression plate (DCP). This meta-analysis was performed to compare fracture union, functional outcomes, and complication rates in patients treated with IMN or DCP for humeral shaft fractures and to develop GRADE (Grading of Recommendations, Assessment, Development, and Evaluation)-based recommendations for using the procedures to treat humeral shaft fractures. A systematic search of all the studies published through December 2012 was conducted using the Medline, Embase, Sciencedirect, OVID and Cochrane Central databases. The randomized controlled trials (RCTs) and quasi-RCTs that compared IMN with DCP in treating adult patients with humeral shaft fractures and provided data regarding the safety and clinical effects were identified. The demographic characteristics, adverse events and clinical outcomes were manually extracted from all of the selected studies. Ten studies that included a total of 448 patients met the inclusion criteria. The results of a meta-analysis indicated that both IMN and DCP can achieve similar fracture union with a similar incidence of radial nerve injury and infection. IMN was associated with an increased risk of shoulder impingement, more restriction of shoulder movement, an increased risk of intraoperative fracture comminution, a higher incidence of implant failure, and an increased risk of re-operation. The overall GRADE system evidence quality was very low, which reduces our confidence in the recommendations of this system. DCP may be superior to IMN in the treatment of humeral shaft fractures. Because of the low quality evidence currently available, high-quality RCTs are required.", "author" : [ { "dropping-particle" : "", "family" : "Ma", "given" : "JianXiong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Xing", "given" : "Dan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ma", "given" : "XinLong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gao", "given" : "Feng", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wei", "given" : "Qiang", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jia", "given" : "HaoBo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feng", "given" : "Rui", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yu", "given" : "JingTao", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wang", "given" : "Jie", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "PloS one", "id" : "ITEM-5", "issue" : "12", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "e82075", "title" : "Intramedullary nail versus dynamic compression plate fixation in treating humeral shaft fractures: grading the evidence through a meta-analysis.", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] }, { "id" : "ITEM-6", "itemData" : { "ISSN" : "0001-6470", "PMID" : "10366912", "abstract" : "Antegrade intramedullary nailing with four different implants was used in 126 humeral shaft fractures. There were 74 acute fractures, 17 pathologic fractures, 16 fractures malaligned in a hanging cast or brace, 15 fractures with delayed union and 4 fractures that were nailed after failed open reduction and internal fixation. The nonunion rate was 21/95 after primary operation, and after reoperations 14/95. Distraction of the fracture was a significant cause of nonunion, but not type of fracture, localization, implant, and delay between injury and surgery. Shoulder joint function was significantly impaired in 25/67 patients. The patients regarded the result as good or satisfactory in 41/67 of the cases who were followed mean 3 (0.5-10) years. We conclude that antegrade intramedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. It can be recommended as primary treatment only when nonoperative treatment is likely to fail.", "author" : [ { "dropping-particle" : "", "family" : "Flinkkil\u00e4", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hyv\u00f6nen", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lakovaara", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Linden", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ristiniemi", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "H\u00e4m\u00e4l\u00e4inen", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta orthopaedica Scandinavica", "id" : "ITEM-6", "issue" : "2", "issued" : { "date-parts" : [ [ "1999", "4" ] ] }, "page" : "133-6", "title" : "Intramedullary nailing of humeral shaft fractures. A retrospective study of 126 cases.", "type" : "article-journal", "volume" : "70" }, "uris" : [ "" ] }, { "id" : "ITEM-7", "itemData" : { "ISSN" : "0022-5282", "PMID" : "11265036", "abstract" : "OBJECTIVE: To assess results of exchange nailing in nonunion after intramedullary (IM) nailing of humeral shaft fractures.\n\nMETHODS: This was a retrospective study; 24 patients with nonunion after IM nailing of humeral shaft fractures were reviewed. In 13 cases, nonunion was treated using exchange nailing, and 11 patients were treated nonoperatively. Union was assessed from radiographs. Shoulder joint symptoms and function were assessed after a mean 4.7 years' follow-up using Constant-Murley scoring and self-administered questionnaires devised by L'Insalata et al.\n\nRESULTS: Single or repeated exchange nailing resulted in union in 6 of 13 patients. Shoulder joint function was satisfactory (mean Constant-Murley score of 72) for those patients whose fracture eventually united and poor (mean Constant-Murley score of 39) for those left with nonunion.\n\nCONCLUSION: Exchange nailing results in a poor union rate in nonunion after IM nailing of humeral shaft fractures. Permanent nonunion of the humeral shaft leaves the patient with severe disability.", "author" : [ { "dropping-particle" : "", "family" : "Flinkkil\u00e4", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ristiniemi", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "H\u00e4m\u00e4l\u00e4inen", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of trauma", "id" : "ITEM-7", "issue" : "3", "issued" : { "date-parts" : [ [ "2001", "3" ] ] }, "page" : "540-4", "title" : "Nonunion after intramedullary nailing of humeral shaft fractures.", "type" : "article-journal", "volume" : "50" }, "uris" : [ "" ] }, { "id" : "ITEM-8", "itemData" : { "ISSN" : "0301-620X", "PMID" : "8300675", "abstract" : "We report our experience with a modified implant and a new technique for locked intramedullary nailing of the humerus in 41 patients. Locking was by cross-screws placed from lateral to medial in the proximal humerus, and anteroposteriorly in the distal humerus. Early in the series, 11 nails were inserted at the shoulder, but we found that rehabilitation was faster after retrograde nailing through the olecranon fossa, which was used for the other 30. We used a closed technique for 29 of the nailings. Of the 41 patients treated, 21 had acute fractures, five had nonunion, and 15 had pathological fractures. Secure fixation was obtained for comminuted and osteoporotic fractures in any part of the humeral shaft, which allowed the early use of crutches and walking frames. Two nails were locked at only one end, and one of these became the only failure of union after an acute fracture.", "author" : [ { "dropping-particle" : "", "family" : "Ingman", "given" : "A M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Waters", "given" : "D A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-8", "issue" : "1", "issued" : { "date-parts" : [ [ "1994", "1" ] ] }, "page" : "23-9", "title" : "Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique, and clinical results.", "type" : "article-journal", "volume" : "76" }, "uris" : [ "" ] }, { "id" : "ITEM-9", "itemData" : { "DOI" : "10.3109/17453674.2014.927729", "ISSN" : "1745-3682", "PMID" : "24930545", "abstract" : "BACKGROUND: Treatment of an acute total hip arthroplasty (THA) infection aims at control of the infection with retention of the implant by surgical debridement and antibiotic treatment. There is no clear evidence whether a single surgical debridement is sufficient or whether multiple procedures are necessary for optimal treatment.\n\nMETHODS: From a prospective database of patients with acute THA infection, we retrospectively reviewed 68 patients treated in 2 large teaching hospitals. Hospital S used a protocol in which each patient received a single surgical debridement and only additional surgery if infectious symptoms persisted (group S; n = 33). In hospital M, patients always received multiple surgical debridements (group M; n = 35). Both groups received systemic antibiotic treatment. Removal of the implant or persistent infection at follow-up was considered failure of treatment. Mean follow-up of the patients was 5 (2-11) years.\n\nRESULTS: Mean time between implantation and debridement was 19 days. 4 patients in group S were considered failure, as opposed to 10 patients in group M (p = 0.09). 9 patients in group S had additional surgery, which resulted in 3 of the 4 failures. At final follow-up, 30 patients in group S and 33 patients in group M had a good clinical result (p = 0.6).\n\nINTERPRETATION: In patients with acute THA infection, a single debridement with only additional surgery on indication appears to be at least as successful for retention of the primary implant and control of infection as a strategy with multiple surgical debridements.", "author" : [ { "dropping-particle" : "", "family" : "Moojen", "given" : "Dirk Jan F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zwiers", "given" : "Jasper H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Scholtes", "given" : "Vanessa A B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Verheyen", "given" : "Cees C P M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Poolman", "given" : "Rudolf W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta orthopaedica", "id" : "ITEM-9", "issue" : "4", "issued" : { "date-parts" : [ [ "2014", "8" ] ] }, "page" : "383-8", "title" : "Similar success rates for single and multiple debridement surgery for acute hip arthroplasty infection.", "type" : "article-journal", "volume" : "85" }, "uris" : [ "" ] }, { "id" : "ITEM-10", "itemData" : { "ISSN" : "0001-6462", "PMID" : "9415724", "abstract" : "The results of the operative treatment of 27 humeral shaft fractures treated at the University of Louisville during a 2-year period were reviewed. The aim of this study was to analyze 1) the indications and results of surgical treatment, 2) the indications for nailing versus plating, and 3) the failures and their treatment (especially surgical nonunions). Indications for surgery were polytrauma patients (including open fractures, associated neurovascular injuries, associated ipsilateral forearm injuries) and isolated unstable fractures in which closed reduction failed. Plate and screw osteosynthesis was used in patients with proximal and distal fractures, in the presence of neurovascular injuries, progressive radial nerve palsy and failure of closed reduction due to interposition of soft tissue. Intramedullary antegrade nailing was preferentially used in polytrauma patients. Seven patients (25%) needed further surgery because of nonunion. The frequency was higher after plating (30%) than after nailing (20%), it was more common in comminuted fractures, middle third fractures and after insufficient distal locking. Exchange nailing resulted in union in 5 of the 7 cases. Although excellent results with low complication rates are reported in the recent literature following plate and screw osteosynthesis or locked intramedullary nailing, we found that operative treatment of difficult humeral shaft fractures is still fraught with a high complication rate.", "author" : [ { "dropping-particle" : "", "family" : "Mulier", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seligson", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sioen", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bergh", "given" : "J", "non-dropping-particle" : "van den", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reynaert", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta orthopaedica Belgica", "id" : "ITEM-10", "issue" : "3", "issued" : { "date-parts" : [ [ "1997", "9" ] ] }, "page" : "170-7", "title" : "Operative treatment of humeral shaft fractures.", "type" : "article-journal", "volume" : "63" }, "uris" : [ "" ] }, { "id" : "ITEM-11", "itemData" : { "ISSN" : "0301-620X", "PMID" : "7822403", "abstract" : "We treated 39 patients with fractures of the humeral shaft by closed retrograde locked intramedullary nailing, using Russell-Taylor humeral nails. The mean healing time of all fractures was 13.7 weeks. After consolidation, shoulder function was excellent in 92.3% and elbow function excellent in 87.2%. Functional end-results were excellent in 84.6% of patients, moderate in 10.3% and bad in 5.1%. One patient had a postoperative radial nerve palsy, which recovered within three months. There was additional comminution at the fracture site in three patients (7.7%) which did not affect healing, and slight nail migration in two older patients (5.1%). Two patients (5.1%) needed a second procedure because of disturbed fracture healing. One screw breakage was seen in a patient with delayed union. Retrograde locked humeral nailing appears to be a better solution for the stabilisation of fractures of the humeral shaft than anterograde nailing or plate and screw fixation. We found the complication rate to be acceptable and shoulder and elbow function to recover rapidly in most cases.", "author" : [ { "dropping-particle" : "", "family" : "Rommens", "given" : "P M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Verbruggen", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Broos", "given" : "P L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-11", "issue" : "1", "issued" : { "date-parts" : [ [ "1995", "1" ] ] }, "page" : "84-9", "title" : "Retrograde locked nailing of humeral shaft fractures. A review of 39 patients.", "type" : "article-journal", "volume" : "77" }, "uris" : [ "" ] }, { "id" : "ITEM-12", "itemData" : { "DOI" : "10.1002/14651858.CD005959.pub2", "ISSN" : "1469-493X", "PMID" : "21678350", "abstract" : "BACKGROUND: Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. It is unclear whether one method is more effective than the other.\n\nOBJECTIVES: To compare compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults.\n\nSEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2011), The Cochrane Library 2011, Issue 1, MEDLINE and EMBASE (both to February 2011) and trial registries for ongoing trials.\n\nSELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing compression plates and locked intramedullary nail fixation for humeral shaft fractures in adults.\n\nDATA COLLECTION AND ANALYSIS: Two authors independently assessed trial methodology and extracted data. Disagreement was resolved by discussion, or third party adjudication. Treatment effects were assessed using risk ratios for dichotomous data and mean differences for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using a fixed-effect model.\n\nMAIN RESULTS: Five small trials comparing dynamic compression plates with locked intramedullary nailing were included in this review. These involved a total of 260 participants undergoing surgery for either acute fractures or after early failure of conservative treatment. All five trials had methodological flaws, such as the lack of assessor blinding, that could have influenced their findings. There was no significant difference in fracture union between plating and nailing (five trials, RR 1.05; 95% CI 0.97 to 1.13). There was a statistically significant increase in shoulder impingement following nailing when compared with plating (five trials, RR 0.12; 95% CI 0.04 to 0.38). Intramedullary nails were removed significantly more frequently than plates (three trials, RR 0.17; 95% CI 0.04 to 0.76). There was no statistically significant difference between plating and nailing in operating time, blood loss during surgery, iatrogenic radial nerve injury, return to pre-injury occupation by six months or American Shoulder and Elbow Surgeons (ASES) scores.Two further small trials are awaiting classification.\n\nAUTHORS' CONCLUSIONS: The available evidence shows that intramedullary nailing is associated with an increased risk of shoulder impingement, with\u2026", "author" : [ { "dropping-particle" : "", "family" : "Kurup", "given" : "Harish", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hossain", "given" : "Munier", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Andrew", "given" : "J Glynne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Cochrane database of systematic reviews", "id" : "ITEM-12", "issue" : "6", "issued" : { "date-parts" : [ [ "2011", "1" ] ] }, "page" : "CD005959", "title" : "Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[11\u201322]", "plainTextFormattedCitation" : "[11\u201322]", "previouslyFormattedCitation" : "[11\u201322]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[11–22]. Infection has been found to be a cause in ~30% of femoral and tibial diaphyseal nonunions following IM nailingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2015.09.027", "ISSN" : "1879-0267", "PMID" : "26489394", "abstract" : "The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.", "author" : [ { "dropping-particle" : "", "family" : "Tsang", "given" : "STJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mills", "given" : "LA", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baren", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frantzias", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "JF", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "AHRW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2015", "12" ] ] }, "page" : "2404-9", "title" : "Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure.", "type" : "article-journal", "volume" : "46" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Tsang", "given" : "STJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mills", "given" : "Leanora Anne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baren", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frantzias", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "J F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A Hamish R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone and joint journal", "id" : "ITEM-2", "issue" : "4", "issued" : { "date-parts" : [ [ "2016" ] ] }, "page" : "534-541", "title" : "Exchange nailing for nonunion of diaphyseal fractures of the tibia. Our results and an analysis of the risk factors for failure", "type" : "article-journal", "volume" : "98 B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[23,24]", "plainTextFormattedCitation" : "[23,24]", "previouslyFormattedCitation" : "[23,24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[23,24]. The rate of infected non-unions has been found to be lower in the humerus at ~4%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "1624516", "abstract" : "We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.", "author" : [ { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bell", "given" : "K M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Court-Brown", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "M M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "1992", "7" ] ] }, "page" : "558-62", "title" : "Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0890-5339", "PMID" : "8892150", "abstract" : "We reviewed 21 cases of humeral nonunion following the failure of \"locking\" humeral nails. The nails had been inserted as the primary operative procedure following humeral fracture in fifteen cases or after the failure of closed treatment in six cases. Reconstruction after the failure of these implants was complicated by poor bone stock and difficulty in achieving union. Although technically difficult, open reduction and internal fixation with plating and bone grafting (successful in nine of nine cases) was more consistent than exchange nailing (successful in four of 10 cases) in achieving union (p = 0.01). Two patients refused further surgical intervention. The degree of bone loss associated with a loose nail, the lack of success of exchange nailing, and the insertion site morbidity associated with humeral nail removal differentiate these nonunions from similar lower extremity problems. The degree of bone loss following failed locking nailing of the humerus is a major concern, and exchange nailing alone may not be an acceptable option to deal with this problem.", "author" : [ { "dropping-particle" : "", "family" : "McKee", "given" : "M D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Miranda", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riemer", "given" : "B L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Blasier", "given" : "R B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Redmond", "given" : "B J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sims", "given" : "S H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Waddell", "given" : "J P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jupiter", "given" : "J B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-2", "issue" : "7", "issued" : { "date-parts" : [ [ "1996", "1" ] ] }, "page" : "492-9", "title" : "Management of humeral nonunion after the failure of locking intramedullary nails.", "type" : "article-journal", "volume" : "10" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[13,25]", "plainTextFormattedCitation" : "[13,25]", "previouslyFormattedCitation" : "[13,25]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[13,25]. There is currently no consensus regarding the treatment of infected non-unions following IM nailingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2106/jbjs.f.00742", "ISSN" : "0021-9355", "author" : [ { "dropping-particle" : "", "family" : "Brinker", "given" : "M R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "D P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-American Volume", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 33\nBrinker, Mark R. O'Connor, Daniel P.\n45", "page" : "177-188", "title" : "Exchange nailing of ununited fractures", "type" : "article-journal", "volume" : "89A" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26]", "plainTextFormattedCitation" : "[26]", "previouslyFormattedCitation" : "[26]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26], but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. (1) General treatment conceptsInfected nonunions have 2 interrelated orthopaedic problems; (a) deep bone infection and (b) a failure of fracture healing. Various strategies exist, which treat:the fracture then the infection definitively, (e.g. exchange IM nailing)the infection definitively then the fracture, (e.g. excision of the non-union and secondary bone transport or Masquelet technique)both at the same time, (e.g. acute shortening)neither specifically (e.g. amputation) In order to decide which strategy is best for a given patient with an intramedullary nailed fracture, that has a failure of healing associated with infection, it is important to determine whether the infection can be suppressed and the fracture healing recommenced with adjunctive treatments until union has occurred. If this is possible then a treatment programme with a shorter rehabilitation time can be offered to the patient. If this is not possible, then it will be necessary to excise the nonunion. For all 4 of the strategies above, deep tissue samplingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0095-1137", "PMID" : "9738046", "abstract" : "A prospective study was performed to establish criteria for the microbiological diagnosis of prosthetic joint infection at elective revision arthroplasty. Patients were treated in a multidisciplinary unit dedicated to the management and study of musculoskeletal infection. Standard multiple samples of periprosthetic tissue were obtained at surgery, Gram stained, and cultured by direct and enrichment methods. With reference to histology as the criterion standard, sensitivities, specificities, and likelihood ratios (LRs) were calculated by using different cutoffs for the diagnosis of infection. We performed revisions on 334 patients over a 17-month period, of whom 297 were evaluable. The remaining 37 were excluded because histology results were unavailable or could not be interpreted due to underlying inflammatory joint disease. There were 41 infections, with only 65% of all samples sent from infected patients being culture positive, suggesting low numbers of bacteria in the samples taken. The isolation of an indistinguishable microorganism from three or more independent specimens was highly predictive of infection (sensitivity, 65%; specificity, 99.6%; LR, 168.6), while Gram staining was less useful (sensitivity, 12%; specificity, 98%; LR, 10). A simple mathematical model was developed to predict the performance of the diagnostic test. We recommend that five or six specimens be sent, that the cutoff for a definite diagnosis of infection be three or more operative specimens that yield an indistinguishable organism, and that because of its low level of sensitivity, Gram staining should be abandoned as a diagnostic tool at elective revision arthroplasty.", "author" : [ { "dropping-particle" : "", "family" : "Atkins", "given" : "B L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Athanasou", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Deeks", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crook", "given" : "D W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peto", "given" : "T E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McLardy-Smith", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berendt", "given" : "A R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical microbiology", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "1998", "10" ] ] }, "page" : "2932-9", "title" : "Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group.", "type" : "article-journal", "volume" : "36" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[27]", "plainTextFormattedCitation" : "[27]", "previouslyFormattedCitation" : "[27]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[27] and the delivery of systemic and/or local antibiotic therapy guided by culture results is routine.The guiding principles for the management of infected nonunions regardless of previous fixation method includes:Surgical debridement with excision/removal of necrotic and foreign materialDead space management.Bone stabilisationWound closure (direct or with soft tissue reconstruction)Reconstitution of skeletal integrity Current controversy lies in the choice of fixation modality to achieve bone stabilityADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2106/jbjs.f.00742", "ISSN" : "0021-9355", "author" : [ { "dropping-particle" : "", "family" : "Brinker", "given" : "M R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "D P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-American Volume", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 33\nBrinker, Mark R. O'Connor, Daniel P.\n45", "page" : "177-188", "title" : "Exchange nailing of ununited fractures", "type" : "article-journal", "volume" : "89A" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26]", "plainTextFormattedCitation" : "[26]", "previouslyFormattedCitation" : "[26]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26], optimal delivery of local antibioticsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.93B2.24933", "ISSN" : "0301-620X", "PMID" : "21282751", "abstract" : "Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity. This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.", "author" : [ { "dropping-particle" : "", "family" : "El-Husseiny", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacFarlane", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haddad", "given" : "F S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011", "2" ] ] }, "page" : "151-7", "title" : "Biodegradable antibiotic delivery systems.", "type" : "article-journal", "volume" : "93" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "1090-3941", "PMID" : "25433347", "abstract" : "Osteomyelitis is a bone infection accompanied by inflammatory process, which can lead to destruction and bone necrosis. It is difficult to manage, and there are no commonly accepted guidelines. While most acute bone infections are usually successfully treated with intravenous antibiotics, chronic infections and infections in the presence of foreign materials usually require operative treatment with debridement, removal of metals, intravenous antibiotics, and very often local antibiotics. The aim of this study was to perform a systematic review of the existing literature concerning the use of bone grafts as carriers for local antibiotic delivery for the treatment and prevention of bone infections. According to the literature, antibiotic-loaded autologous bone grafts for the treatment of infected tibial nonunion is a good option (Grade-B recommendations). Although there are several studies concerning the use of antibiotic-loaded allogenic bone grafts in infected joint arthroplasty revisions, there is a lack of comparative studies (Grade-C recommendations). Studies concerning spinal fusion and spondylodiscitis are limited (Grade-I recommendations).", "author" : [ { "dropping-particle" : "", "family" : "Lalidou", "given" : "Fani", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kolios", "given" : "George", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tavridou", "given" : "Anna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Drosos", "given" : "Georgios I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgical technology international", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2014", "11" ] ] }, "page" : "239-45", "title" : "Bone grafts as carriers for local antibiotic delivery for the treatment and prevention of bone infections.", "type" : "article-journal", "volume" : "25" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[28,29]", "plainTextFormattedCitation" : "[28,29]", "previouslyFormattedCitation" : "[28,29]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[28,29] and the methods required to reconstitute bone lossADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2016.01.023", "ISSN" : "00201383", "author" : [ { "dropping-particle" : "V.", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2016", "2" ] ] }, "page" : "291-292", "title" : "Treatment of bone defects: Bone transport or the induced membrane technique?", "type" : "article-journal", "volume" : "47" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[30]", "plainTextFormattedCitation" : "[30]", "previouslyFormattedCitation" : "[30]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[30](2) General considerations when formulating a treatment strategy for infected nonunions following intramedullary fixation.(a) Host factorsThe age of the patient, the presence of chronic disease (e.g. diabetes mellitus), use of medications, alcohol consumption and tobacco usage may alter the potential to eradicate the infection and for the bone defects to healADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620x.89b12", "ISSN" : "0301-620X", "abstract" : "This paper reviews the current literature concerning the main clinical factors which can impair the healing of fractures and makes recommendations on avoiding or minimising these in order to optimise the outcome for patients. The clinical implications are described.", "author" : [ { "dropping-particle" : "", "family" : "Gaston", "given" : "M S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-British Volume", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 43\nSimpson, Alasdair/F-1887-2013\nSimpson, Alasdair/0000-0001-7793-642X\n45", "page" : "1553-1560", "title" : "Inhibition of fracture healing", "type" : "article-journal", "volume" : "89B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[31]", "plainTextFormattedCitation" : "[31]", "previouslyFormattedCitation" : "[31]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[31]. Modifiable host risk factors for nonunion should be addressed in the pre-operative periodADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BOT.0000000000000151", "ISSN" : "1531-2291", "PMID" : "24824097", "abstract" : "OBJECTIVES: The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral and 4 segmental) who presented with an intramedullary nail on an average of 16 months after the initial treatment were presented in this study. INTERVENTION: Insertion of an exchange nail of at least >2-mm diameter than the prior nail using a different manufacturer's nail, static interlocking, partial fibulectomy in a select group of patients, and correction of underlying metabolic and endocrine abnormalities. MAIN OUTCOME MEASUREMENTS: Union rate, time to union. RESULTS: Forty-five of 46 tibial nonunion sites (98%) healed at an average of 4.8 months. CONCLUSIONS: Patient selection criteria and a systematic approach to exchange nailing for tibial nonunion is highly successful. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.", "author" : [ { "dropping-particle" : "", "family" : "Swanson", "given" : "Eli A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garrard", "given" : "Eli C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O\u02bcConnor", "given" : "Daniel P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brinker", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2015", "1" ] ] }, "page" : "28-35", "title" : "Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1097/BOT.0000000000000166", "ISSN" : "1531-2291", "PMID" : "24978947", "abstract" : "OBJECTIVES:: To evaluate the radiographic and clinical outcomes of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions previously treated with an intramedullary nail. DESIGN:: Retrospective cohort. SETTING:: Tertiary referral center. PATIENTS:: 50 aseptic femoral nonunions in 49 patients who presented with an intramedullary nail in situ an average of 25 months after the initial fracture nailing were evaluated. INTERVENTION:: Our systematic approach includes inserting an exchange nail at least 2 mm larger in diameter than the in situ nail, using a different manufacturer's nail, static interlocking, correction of any metabolic and endocrine abnormalities, and secondary nail dynamization in cases showing slow progression toward healing. MAIN OUTCOMES MEASUREMENTS:: The outcome measures were radiographic and clinical evidence of nonunion healing and time to union. RESULTS:: All 50 femoral nonunions (100%) healed following this systematic approach to exchange nailing. The average time to achieve union was 7 months (range, 3 to 26 months). CONCLUSIONS:: Utilization of this systematic approach of exchange nailing for treatment of aseptic femoral nonunions resulted in a 100% healing rate. LEVEL OF EVIDENCE:: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.", "author" : [ { "dropping-particle" : "", "family" : "Swanson", "given" : "Eli A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garrard", "given" : "Eli C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bernstein", "given" : "Derek T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Daniel P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brinker", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "6", "26" ] ] }, "page" : "21-7", "title" : "The Results of a Systematic Approach to Exchange Nailing for the Treatment of Aseptic Femoral Nonunions.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/s0020-1383(08)70016-0", "ISSN" : "0020-1383", "PMID" : "18804575", "abstract" : "SUMMARY: A new scoring system is proposed in order to assist surgeons with the complex analysis associated with non-union surgery. Patients with non-union are rarely easily compared with one another and this has frustrated research in this field. We have therefore attributed values to clinical features based on clinical experience and research evidence, so that patients of similar complexity can be compared with one another. When greater experience with this scoring system has been gained it will be further refined and validated. We propose that surgeons with a sub specialist interest in non-union surgery use this system in reporting results, and that non- specialist surgeons use it to inform their decision to treat the fracture themselves, or refer to a sub specialist.", "author" : [ { "dropping-particle" : "", "family" : "Calori", "given" : "Giorgio Maria", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Phillips", "given" : "Mark", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jeetle", "given" : "Sharanpal", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tagliabue", "given" : "Lorenzo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury-International Journal of the Care of the Injured", "genre" : "JOUR", "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "2008", "9" ] ] }, "note" : "From Duplicate 1 ( \n\n\nClassification of non-union: Need for a new scoring system?\n\n\n- Calori, Giorgio Maria; Phillips, Mark; Jeetle, Sharanpal; Tagliabue, Lorenzo; Giannoudis, P V )\n\n\n\nTimes Cited: 5\n2\n5th European Symposium on Tissue Engineering Bone Biology Congress\nSEP 04, 2008-AUG 06, 2009\nBerlin, GERMANY", "page" : "S59-S63", "title" : "Classification of non-union: Need for a new scoring system?", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[32\u201334]", "plainTextFormattedCitation" : "[32\u201334]", "previouslyFormattedCitation" : "[32\u201334]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[32–34]. (b) Antibiotic TherapySystemic antibiotic treatment may be inadequate or ineffective in patients with poorly vascularised infected tissues and osteonecrosis, which is often present in cases of osteomyelitisADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.93B2.24933", "ISSN" : "0301-620X", "PMID" : "21282751", "abstract" : "Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity. This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.", "author" : [ { "dropping-particle" : "", "family" : "El-Husseiny", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacFarlane", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haddad", "given" : "F S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011", "2" ] ] }, "page" : "151-7", "title" : "Biodegradable antibiotic delivery systems.", "type" : "article-journal", "volume" : "93" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[28]", "plainTextFormattedCitation" : "[28]", "previouslyFormattedCitation" : "[28]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[28]. Moreover, the bacteria have the ability to produce a protective hydrated matrix of polysaccharide and protein, forming a slimy layer known as a biofilm. A biofilm can be further defined as an ‘assemblage of microbial cells that is irreversibly associated with a surface and enclosed in a matrix of primarily polysaccharide materialADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Donlan", "given" : "R M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Emerging Infectious Diseases", "edition" : "8", "genre" : "BOOK", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "881-890", "title" : "Biofilms: Microbial life on surfaces.", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[35]", "plainTextFormattedCitation" : "[35]", "previouslyFormattedCitation" : "[35]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[35]. Internal fixation or inadequate debridement provides a nidus for bacterial adherence and biofilm formation. Bacterial biofilms play a role in the majority of recalcitrant healthcare-associated infections such as periprosthetic joint infections and chronic osteomyelitisADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "O'Gara", "given" : "J P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Humphreys", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Medical Microbiology", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "582-587", "title" : "Staphylococcus epidermidis biofilms: importance and implications.", "type" : "article-journal", "volume" : "50" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[36]", "plainTextFormattedCitation" : "[36]", "previouslyFormattedCitation" : "[36]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[36]. Formation of biofilms leads to a reduction in antimicrobial susceptibility in many bacterial species, such as Staphylococcus. One mechanism is the failure of antimicrobial agents to penetrate the full depth of the biofilm due to the presence of an exopolysaccharide matrix. Secondly, the growth rate of bacterial cells within a biofilm is substantially reduced in comparison with planktonic cells as cells growing in biofilms are commonly nutrient depletedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Mah", "given" : "T F C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Toole", "given" : "G A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Trends in Microbiology.", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "34-39.", "title" : "Mechanisms of biofilm resistance to antimicrobial agents.", "type" : "article-journal", "volume" : "9" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[37]", "plainTextFormattedCitation" : "[37]", "previouslyFormattedCitation" : "[37]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[37]. Reduced growth rates lead to reduced susceptibility to antimicrobials designed to target fast growing and reproductive planktonic bacterial cells. The reduced metabolic activity of bacterial cells embedded within biofilms mimic this nutrient depleted state correlating with reduced antimicrobial susceptibility. Finally, it has been hypothesised that cells present in a biofilm may induce a specific ‘biofilm phenotype’. This ‘biofilm phenotype’ has been likened to a spore-like state entered into by some of the bacteria resulting in reduced susceptibility to antibiotics and disinfectants. Reduced antimicrobial susceptibility to ?-lactams, quinolones and glycopeptides has been observed in biofilms formed by S. aureus ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Chuard", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vaudaux", "given" : "P E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Proctor", "given" : "R A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lew", "given" : "D P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Antimicrobial Chemotheropy", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "1997" ] ] }, "page" : "603-608.", "title" : "Decreased susceptibility to antibiotic killing of a stable small colony variant of Staphylococcus aureus in fluid phase and on fibronectin-coated surfaces.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[38]", "plainTextFormattedCitation" : "[38]", "previouslyFormattedCitation" : "[38]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[38]. Minimum inhibitory concentrations (MIC) required to treat sessile bacteria within biofilms have been shown to be up 800 greater than that required in the treatment of planktonic cellsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0021-9355", "PMID" : "3881449", "abstract" : "The direct examination of tissue and biomaterials from prosthesis-related infections of twenty-five patients showed that the causative bacteria grew in glycocalyx-enclosed biofilms that were adherent to surfaces of biomaterials and tissues in 76 per cent. This high rate of recovery of adherent biofilm-mediated growth suggests that the process occurs commonly in the presence of a foreign body or biomaterial-related infection. Because of the adherent mode of growth of the infecting organisms, accurate microbiological sampling was difficult. The analysis of joint fluids or of swabs of excised tissue and of prosthetic surfaces often yielded only one species from what was a polymicrobial population based on electron microscopic studies. We adapted direct quantitative sampling methods from environmental microbiology in order to recover a large number of species from these infections, but comparison of the organisms isolated by these techniques with the morphological types that were seen by electron microscopy indicated that in some instances all bacterial components of the biofilms were still not being recovered.", "author" : [ { "dropping-particle" : "", "family" : "Gristina", "given" : "A G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Costerton", "given" : "J W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. American volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "1985", "2" ] ] }, "page" : "264-73", "title" : "Bacterial adherence to biomaterials and tissue. The significance of its role in clinical sepsis.", "type" : "article-journal", "volume" : "67" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1146/annurev.mi.49.100195.003431", "ISSN" : "0066-4227", "PMID" : "8561477", "abstract" : "Direct observations have clearly shown that biofilm bacteria predominate, numerically and metabolically, in virtually all nutrient-sufficient ecosystems. Therefore, these sessile organisms predominate in most of the environmental, industrial, and medical problems and processes of interest to microbiologists. If biofilm bacteria were simply planktonic cells that had adhered to a surface, this revelation would be unimportant, but they are demonstrably and profoundly different. We first noted that biofilm cells are at least 500 times more resistant to antibacterial agents. Now we have discovered that adhesion triggers the expression of a sigma factor that derepresses a large number of genes so that biofilm cells are clearly phenotypically distinct from their planktonic counterparts. Each biofilm bacterium lives in a customized microniche in a complex microbial community that has primitive homeostasis, a primitive circulatory system, and metabolic cooperativity, and each of these sessile cells reacts to its special environment so that it differs fundamentally from a planktonic cell of the same species.", "author" : [ { "dropping-particle" : "", "family" : "Costerton", "given" : "J W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lewandowski", "given" : "Z", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Caldwell", "given" : "D E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Korber", "given" : "D R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lappin-Scott", "given" : "H M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annual review of microbiology", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "1995", "1", "28" ] ] }, "language" : "en", "page" : "711-45", "publisher" : "Annual Reviews 4139 El Camino Way, P.O. Box 10139, Palo Alto, CA 94303-0139, USA", "title" : "Microbial biofilms.", "type" : "article-journal", "volume" : "49" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Stewart", "given" : "P S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Costerton", "given" : "J W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Lancet", "genre" : "JOUR", "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "135-138", "title" : "Antibiotic resistance of bacteria in biofilms.", "type" : "article-journal", "volume" : "358" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[39\u201341]", "plainTextFormattedCitation" : "[39\u201341]", "previouslyFormattedCitation" : "[39\u201341]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[39–41]. Systemic antibiotics cannot reach such high concentrations at the bone-biofilm interface site and as such can be ineffective. Certain bacteria such as mycobacteria are a particular problem in immunocompromised patients and need special antibiotic regimensADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.97B9.35227", "ISSN" : "2049-4408", "PMID" : "26330597", "abstract" : "In this retrospective observational cohort study, we describe 17 patients out of 1775 treated for various fractures who developed mycobacterium tuberculosis (MTB) infection after surgery. The cohort comprised 15 men and two women with a mean age of 40 years (24 to 70). A total of ten fractures were open and seven were closed. Of these, seven patients underwent intramedullary nailing of a fracture of the long bone, seven had fractures fixed with plates, two with Kirschner-wires and screws, and one had a hemiarthroplasty of the hip with an Austin Moore prosthesis. All patients were followed-up for two years. In all patients, the infection resolved, and in 14 the fractures united. Nonunion was seen in two patients one of whom underwent two-stage total hip arthroplasty (THA) and the other patient was treated using excision arthoplasty. Another patient was treated using two-stage THA. With only sporadic case reports in the literature, MTB infection is rarely clinically suspected, even in underdeveloped and developing countries, where pulmonary and other forms of TB are endemic. In developed countries there is also an increased incidence among immunocompromised patients. In this paper we discuss the pathogenesis and incidence of MTB infection after surgical management of fractures and suggest protocols for early diagnosis and management.", "author" : [ { "dropping-particle" : "", "family" : "Mahale", "given" : "Y J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Aga", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2015", "9" ] ] }, "page" : "1279-83", "title" : "Implant-associated mycobacterium tuberculosis infection following surgical management of fractures: a retrospective observational study.", "type" : "article-journal", "volume" : "97-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[42]", "plainTextFormattedCitation" : "[42]", "previouslyFormattedCitation" : "[42]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[42]. A further postulated cause of recalcitrant infection is the presence of bacteria within host cells, such as osteoblastsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0019-9567", "PMID" : "11500391", "abstract" : "Staphylococcus aureus invades osteoblasts and can persist in the intracellular environment. The present study examined the role of osteoblast mitogen-activated protein kinase (MAPK) pathways in bacterial invasion. S. aureus infection of normal human and mouse osteoblasts resulted in an increase in the phosphorylation of the extracellular signal-regulated protein kinases (ERK 1 and 2). This stimulation of ERK 1 and 2 correlated with the time course of S. aureus invasion, and bacterial adherence induced the MAPK pathway. ERK 1 and 2 phosphorylation was time and dose dependent and required active S. aureus gene expression for maximal induction. The nonpathogenic Staphylococcus carnosus was also able to induce ERK 1 and 2 phosphorylation, albeit at lower levels than S. aureus. Phosphorylation of the stress-activated protein kinases was increased in both infected human and mouse osteoblasts; however, the p38 MAPK pathway was not activated in response to S. aureus. Finally, the transcription factor c-Jun, but not Elk-1 or ATF-2, was phosphorylated in response to S. aureus infection.", "author" : [ { "dropping-particle" : "", "family" : "Ellington", "given" : "J K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Elhofy", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bost", "given" : "K L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hudson", "given" : "M C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Infection and immunity", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2001", "9" ] ] }, "page" : "5235-42", "title" : "Involvement of mitogen-activated protein kinase pathways in Staphylococcus aureus invasion of normal osteoblasts.", "type" : "article-journal", "volume" : "69" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[43]", "plainTextFormattedCitation" : "[43]", "previouslyFormattedCitation" : "[43]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[43]. The intracellular location of the bacteria protects them from the host immune system and from antibiotics, except for a few such as rifampicinADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1473-2262", "PMID" : "25340805", "abstract" : "Staphylococcus aureus is the most clinically relevant pathogen regarding implant-associated bone infection and its capability to invade osteoblasts is well known. The aim of this study was to investigate firstly whether S. aureus is not only able to invade but also to proliferate within osteoblasts, secondly to delineate the mechanism of invasion and thirdly to clarify whether rifampicin or gentamicin can inhibit intracellular proliferation and survival of S. aureus. The SAOS-2 osteoblast-like cell line and human primary osteoblasts were infected with S. aureus EDCC5055 and S. aureus Rosenbach 1884. Both S. aureus strains were able to invade efficiently and to proliferate within human osteoblasts. Immunofluorescence microscopy showed intracellular invasion of S. aureus and transmission electron microscopy images could demonstrate bacterial division as a sign of intracellular proliferation as well as cytosolic bacterial persistence. Cytochalasin D, the major actin depolymerisation agent, was able to significantly reduce S. aureus invasion, suggesting that invasion was enabled by promoting actin rearrangement at the cell surface. 7.5 \u03bcg/mL of rifampicin was able to inhibit bacterial survival in SAOS-2 cells with almost complete elimination of bacteria after 4 h. Gentamicin could also kill intracellular S. aureus in a dose-dependent manner, an effect that was significantly lower than that observed using rifampicin. In conclusion, S. aureus is not only able to invade but also to proliferate in osteoblasts. Invasion seems to be associated with actin rearrangement at the cell surface. Rifampicin is effective in intracellular eradication of S. aureus whereas gentamicin only poorly eliminates intracellularly replicating bacteria.", "author" : [ { "dropping-particle" : "", "family" : "Mohamed", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sommer", "given" : "U", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sethi", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Domann", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thormann", "given" : "U", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sch\u00fctz", "given" : "I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lips", "given" : "K S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chakraborty", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnettler", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Alt", "given" : "V", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European cells & materials", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "258-68", "title" : "Intracellular proliferation of S. aureus in osteoblasts and effects of rifampicin and gentamicin on S. aureus intracellular proliferation and survival.", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[44]", "plainTextFormattedCitation" : "[44]", "previouslyFormattedCitation" : "[44]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[44]. Thus, the local delivery of antibiotics appears to be a key component of the success of the overall management of infected nonunionsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2015.08.009", "ISSN" : "1879-0267", "PMID" : "26304000", "abstract" : "Infected non-union is a devastating complication post fracture fixation. While its incidence is small, its management is lengthy, challenging and costly. Complex reconstruction surgery is often required with unpredictable outcomes despite the significant advances that have been made in diagnostics, surgical techniques and antibiotic protocols. In this article we present recent approaches to the surgical treatment of this condition.", "author" : [ { "dropping-particle" : "", "family" : "Kanakaris", "given" : "Nikolaos K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tosounidis", "given" : "Theodoros H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2015", "11" ] ] }, "page" : "S25-32", "title" : "Surgical management of infected non-unions: An update.", "type" : "article-journal", "volume" : "46 Suppl 5" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1097/BOT.0b013e31812e5578", "ISSN" : "0890-5339", "author" : [ { "dropping-particle" : "", "family" : "Struijs", "given" : "P A A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Poolman", "given" : "R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bhandari", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 13\nStruijs, Peter A. A. Poolman, Rudolf W. Bhandari, Mohit\n16", "page" : "507-511", "title" : "Infected nonunion of the long bones", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "1090-3941", "PMID" : "25433347", "abstract" : "Osteomyelitis is a bone infection accompanied by inflammatory process, which can lead to destruction and bone necrosis. It is difficult to manage, and there are no commonly accepted guidelines. While most acute bone infections are usually successfully treated with intravenous antibiotics, chronic infections and infections in the presence of foreign materials usually require operative treatment with debridement, removal of metals, intravenous antibiotics, and very often local antibiotics. The aim of this study was to perform a systematic review of the existing literature concerning the use of bone grafts as carriers for local antibiotic delivery for the treatment and prevention of bone infections. According to the literature, antibiotic-loaded autologous bone grafts for the treatment of infected tibial nonunion is a good option (Grade-B recommendations). Although there are several studies concerning the use of antibiotic-loaded allogenic bone grafts in infected joint arthroplasty revisions, there is a lack of comparative studies (Grade-C recommendations). Studies concerning spinal fusion and spondylodiscitis are limited (Grade-I recommendations).", "author" : [ { "dropping-particle" : "", "family" : "Lalidou", "given" : "Fani", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kolios", "given" : "George", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tavridou", "given" : "Anna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Drosos", "given" : "Georgios I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgical technology international", "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "2014", "11" ] ] }, "page" : "239-45", "title" : "Bone grafts as carriers for local antibiotic delivery for the treatment and prevention of bone infections.", "type" : "article-journal", "volume" : "25" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[29,45,46]", "plainTextFormattedCitation" : "[29,45,46]", "previouslyFormattedCitation" : "[29,45,46]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[29,45,46]. Bio-absorbable antibiotic delivery systems. Biodegradable carriers are seen as theoretically advantageous, because of the potential reduction in the risk of persistent or secondary infections and the need for removal of the implant. Examples include allograft boneADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/2046-3758.34.2000223", "ISSN" : "2046-3758", "PMID" : "24729101", "abstract" : "OBJECTIVES: The most concerning infection of allografts and operative procedures is methicillin resistant Staphylococcus aureus (MRSA) and no current iontophoresed antibiotics effectively combat this microbe. It was initially hypothesised that iontophoresis of vancomycin through bone would not be effective due to its large molecular size and lack of charge. The aim of this study was to determine whether this was a viable procedure and to find the optimum conditions for its use.\n\nMETHODS: An iontophoresis cell was set up with varying concentrations of Vancomycin within the medulla of a section of sheep tibia, sealed from an external saline solution. The cell was run for varying times, Vancomycin concentrations and voltages, to gain information on optimisation of conditions for impregnating the graft. Each graft was then sectioned and dust ground from the exposed surface. The dust was serially washed to extract the Vancomycin and concentrations measured and plotted for all variables tested.\n\nRESULTS: Vancomycin was successfully delivered and impregnated to the graft using the iontophoresis technique. The first order fit to the whole data set gave a significant result (p = 0.0233), with a significant concentration (p = 0.02774) component. The time component was the next most significant (p = 0.0597), but did not exceed the 95% confidence level.\n\nCONCLUSIONS: Iontophoresis is an effective method for delivering Vancomycin to allograft bone. The concentrations of the vancomycin solution affected the bone concentration, but results were highly variable. Further study should be done on the effectiveness of delivering different antibiotics using this method. Cite this article: Bone Joint Res 2014;3:101-7.", "author" : [ { "dropping-particle" : "", "family" : "Edmondson", "given" : "M C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Day", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wood", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone & joint research", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "101-7", "title" : "Vancomycin iontophoresis of allograft bone.", "type" : "article-journal", "volume" : "3" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[47]", "plainTextFormattedCitation" : "[47]", "previouslyFormattedCitation" : "[47]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[47], collagen fleecesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2174/1874325001509010372", "ISSN" : "1874-3250", "PMID" : "26322143", "abstract" : "The treatment of chronic osteomyelitis requires both appropriate surgical and antibiotic management. Prolonged intravenous antibiotic therapy followed by oral therapy is widely utilised. Despite this, the long-term recurrence rate can be up to 30%. A cohort of 50 patients from a 7-year period, 2003 to 2010, with chronic osteomyelitis was identified. This cohort was treated by surgical marginal resection in combination with local application of antibiotics (Collatamp G - gentamicin in a collagen fleece), a short course of systemic antibiotics post-operatively and conversion to oral antibiotics on discharge. Information was retrieved from case notes and computerized records. Outcomes from this cohort were compared with a historical cohort treated with marginal resection followed by 6 weeks of systemic antibiotics and 6 weeks of oral antibiotics. The mean follow-up duration was 3.2 years (SD 1.8). The average length of admission was 9.8 days (SD 11.4). 6 patients (12%) suffered recurrence of infection requiring further treatment. We used the Cierny and Mader classification to stratify the patients. 'A' hosts had a shorter duration of admission (7.1 days) than 'B' hosts (12.3 days). There was no significant difference between recurrence rates of 'A' and 'B' hosts. Where available, we found pre-operative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels had no correlation with disease recurrence. Disease-free probability for this cohort compared favourably with the historical cohort. We believe local administration of gentamicin in a collagen fleece is a useful component in the management of chronic osteomyelitis.", "author" : [ { "dropping-particle" : "", "family" : "Leung", "given" : "Andraay H C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hawthorn", "given" : "Benjamin R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A Hamish R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The open orthopaedics journal", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2015", "1" ] ] }, "page" : "372-8", "title" : "The Effectiveness of Local Antibiotics in Treating Chronic Osteomyelitis in a Cohort of 50 Patients with an Average of 4 Years Follow-Up.", "type" : "article-journal", "volume" : "9" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[48]", "plainTextFormattedCitation" : "[48]", "previouslyFormattedCitation" : "[48]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[48], polyesters, polyanhidrides, amylose starch, alginates, chitosans, composite carriersADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.93B2.24933", "ISSN" : "0301-620X", "PMID" : "21282751", "abstract" : "Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity. This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.", "author" : [ { "dropping-particle" : "", "family" : "El-Husseiny", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacFarlane", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haddad", "given" : "F S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011", "2" ] ] }, "page" : "151-7", "title" : "Biodegradable antibiotic delivery systems.", "type" : "article-journal", "volume" : "93" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/0301-620X.97B10.35651", "ISSN" : "2049-4408", "PMID" : "26430020", "abstract" : "Systemic antibiotics reduce infection in open fractures. Local delivery of antibiotics can provide higher doses to wounds without toxic systemic effects. This study investigated the effect on infection of combining systemic with local antibiotics via polymethylmethacrylate (PMMA) beads or gel delivery. An established Staphylococcus aureus contaminated fracture model in rats was used. Wounds were debrided and irrigated six hours after contamination and animals assigned to one of three groups, all of which received systemic antibiotics. One group had local delivery via antibiotic gel, another PMMA beads and the control group received no local antibiotics. After two weeks, bacterial levels were quantified. Combined local and systemic antibiotics were superior to systemic antibiotics alone at reducing the quantity of bacteria recoverable from each group (p = 0.002 for gel; p = 0.032 for beads). There was no difference in the bacterial counts between bead and gel delivery (p = 0.62). These results suggest that local antibiotics augment the antimicrobial effect of systemic antibiotics. Although no significant difference was found between vehicles, gel delivery offers technical advantages with its biodegradable nature, ability to conform to wound shape and to deliver increased doses. Further study is required to see if the gel delivery system has a clinical role.", "author" : [ { "dropping-particle" : "", "family" : "Rand", "given" : "B C C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Penn-Barwell", "given" : "J G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wenke", "given" : "J C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-2", "issue" : "10", "issued" : { "date-parts" : [ [ "2015", "10" ] ] }, "page" : "1423-7", "title" : "Combined local and systemic antibiotic delivery improves eradication of wound contamination: An animal experimental model of contaminated fracture.", "type" : "article-journal", "volume" : "97-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[28,49]", "plainTextFormattedCitation" : "[28,49]", "previouslyFormattedCitation" : "[28,49]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[28,49] and calcium-based carriersADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/2046-3758.37.2000301", "ISSN" : "2046-3758", "PMID" : "25005841", "abstract" : "OBJECTIVE: A clinical investigation into a new bone void filler is giving first data on systemic and local exposure to the anti-infective substance after implantation.\n\nMETHOD: A total of 20 patients with post-traumatic/post-operative bone infections were enrolled in this open-label, prospective study. After radical surgical debridement, the bone cavity was filled with this material. The 21-day hospitalisation phase included determination of gentamicin concentrations in plasma, urine and wound exudate, assessment of wound healing, infection parameters, implant resorption, laboratory parameters, and adverse event monitoring. The follow-up period was six months.\n\nRESULTS: Systemic exposure to gentamicin after implantation was very low as local gentamicin concentrations were measured in wound exudate after six to ten hours. There were no signs of infectious complication throughout the clinical phase. Four patients had recurrent infections several weeks to months after implantation. The outcome was deemed successful by remission of infection in 16 (80%) of these problematic long-term treated patients. Safety laboratory measurements did not indicate nephrotoxic or hepatotoxic effects.\n\nCONCLUSIONS: Local application of calcium sulphate/carbonate bone void filler comprising gentamicin revealed sufficient active local levels of the antibiotic by simultaneous significant low systemic exposure in patients with mostly chronic osteomyelitis/osteitis. The material was safe and well tolerated. Cite this article: Bone Joint Res 2014;3:223-9.", "author" : [ { "dropping-particle" : "", "family" : "Fleiter", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Walter", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "B\u00f6sebeck", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vogt", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "B\u00fcchner", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hirschberger", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hoffmann", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone & joint research", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "2014", "7" ] ] }, "page" : "223-9", "title" : "Clinical use and safety of a novel gentamicin-releasing resorbable bone graft substitute in the treatment of osteomyelitis/osteitis.", "type" : "article-journal", "volume" : "3" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/0301-620X.96B6.33014", "ISSN" : "2049-4408", "PMID" : "24891588", "abstract" : "The treatment of chronic osteomyelitis often includes surgical debridement and filling the resultant void with antibiotic-loaded polymethylmethacrylate cement, bone grafts or bone substitutes. Recently, the use of bioactive glass to treat bone defects in infections has been reported in a limited series of patients. However, no direct comparison between this biomaterial and antibiotic-loaded bone substitute has been performed. In this retrospective study, we compared the safety and efficacy of surgical debridement and local application of the bioactive glass S53P4 in a series of 27 patients affected by chronic osteomyelitis of the long bones (Group A) with two other series, treated respectively with an antibiotic-loaded hydroxyapatite and calcium sulphate compound (Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded demineralised bone matrix (Group C; n = 22). Systemic antibiotics were also used in all groups. After comparable periods of follow-up, the control of infection was similar in the three groups. In particular, 25 out of 27 (92.6%) patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out of 22 (86.3%) in Group C showed no infection recurrence at means of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up, respectively, while Group A showed a reduced wound complication rate. Our results show that patients treated with a bioactive glass without local antibiotics achieved similar eradication of infection and less drainage than those treated with two different antibiotic-loaded calcium-based bone substitutes.", "author" : [ { "dropping-particle" : "", "family" : "Roman\u00f2", "given" : "C L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Logoluso", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meani", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roman\u00f2", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vecchi", "given" : "E", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vassena", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Drago", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-2", "issue" : "6", "issued" : { "date-parts" : [ [ "2014", "6" ] ] }, "page" : "845-50", "title" : "A comparative study of the use of bioactive glass S53P4 and antibiotic-loaded calcium-based bone substitutes in the treatment of chronic osteomyelitis: a retrospective comparative study.", "type" : "article-journal", "volume" : "96-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[50,51]", "plainTextFormattedCitation" : "[50,51]", "previouslyFormattedCitation" : "[50,51]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[50,51]. They have been shown to have better drug elution profiles than PMMA,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.93B2.24933", "ISSN" : "0301-620X", "PMID" : "21282751", "abstract" : "Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity. This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.", "author" : [ { "dropping-particle" : "", "family" : "El-Husseiny", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacFarlane", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haddad", "given" : "F S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011", "2" ] ] }, "page" : "151-7", "title" : "Biodegradable antibiotic delivery systems.", "type" : "article-journal", "volume" : "93" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[28]", "plainTextFormattedCitation" : "[28]", "previouslyFormattedCitation" : "[28]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[28] although methods of enhancing the release of antibiotic have been reportedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/2046-3758.52.2000412", "ISSN" : "2046-3758", "PMID" : "26843512", "abstract" : "OBJECTIVES: The objective of this study was to determine if combining variations in mixing technique of antibiotic-impregnated polymethylmethacrylate (PMMA) cement with low frequency ultrasound (LFUS) improves antibiotic elution during the initial high phase (Phase I) and subsequent low phase (Phase II) while not diminishing mechanical strength.\n\nMETHODS: Three batches of vancomycin-loaded PMMA were prepared with different mixing techniques: a standard technique; a delayed technique; and a control without antibiotic. Daily elution samples were analysed using flow injection analysis (FIA). Beginning in Phase II, samples from each mix group were selected randomly to undergo either five, 15, 45, or 0 minutes of LFUS treatment. Elution amounts between LFUS treatments were analysed. Following Phase II, compression testing was done to quantify strength. A-priori t-tests and univariate ANOVAs were used to compare elution and mechanical test results between the two mix groups and the control group.\n\nRESULTS: The delayed technique showed a significant increase in elution on day one compared with the standard mix technique (p < 0.001). The transition point from Phase I to Phase II occurred on day ten. LFUS treatments significantly increased elution amounts for all groups above control. Delayed technique resulted in significantly higher elution amounts for the five-minute- (p = 0.004) and 45-minute- (p < 0.001) duration groups compared with standard technique. Additionally, the correlations between LFUS duration and total elution amount for both mix techniques were significant (p = 0.03). Both antibiotic-impregnated groups exhibited a significant decrease in offset yield stress compared with the control group (p < 0.001), however, their lower 95% confidence intervals were all above the 70 MPa limit defined by International Standards Organization (ISO) 5833-2 reference standard for acrylic bone cement.\n\nCONCLUSION: The combination of a delayed mix technique with LFUS treatments provides a reasonable means for increasing both short- and long-term antibiotic elution without affecting mechanical strength.Cite this article: Dr. T. McIff. Combination of modified mixing technique and low frequency ultrasound to control the elution profile of vancomycin-loaded acrylic bone cement. Bone Joint Res 2016;5:26-32. doi: 10.1302/2046-3758.52.2000412.", "author" : [ { "dropping-particle" : "", "family" : "Wendling", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mar", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wischmeier", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Anderson", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McIff", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone & joint research", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2016", "2" ] ] }, "page" : "26-32", "title" : "Combination of modified mixing technique and low frequency ultrasound to control the elution profile of vancomycin-loaded acrylic bone cement.", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/2046-3758.38.2000305", "ISSN" : "2046-3758", "PMID" : "25104836", "abstract" : "OBJECTIVES: The objective of this study was to compare the elution characteristics, antimicrobial activity and mechanical properties of antibiotic-loaded bone cement (ALBC) loaded with powdered antibiotic, powdered antibiotic with inert filler (xylitol), or liquid antibiotic, particularly focusing on vancomycin and amphotericin B.\n\nMETHODS: Cement specimens loaded with 2 g of vancomycin or amphotericin B powder (powder group), 2 g of antibiotic powder and 2 g of xylitol (xylitol group) or 12 ml of antibiotic solution containing 2 g of antibiotic (liquid group) were tested.\n\nRESULTS: Vancomycin elution was enhanced by 234% in the liquid group and by 12% in the xylitol group compared with the powder group. Amphotericin B elution was enhanced by 265% in the liquid group and by 65% in the xylitol group compared with the powder group. Based on the disk-diffusion assay, the eluate samples of vancomycin-loaded ALBC of the liquid group exhibited a significantly larger inhibitory zone than samples of the powder or the xylitol group. Regarding the ALBCs loaded with amphotericin B, only the eluate samples of the liquid group exhibited a clear inhibitory zone, which was not observed in either the xylitol or the powder groups. The ultimate compressive strength was significantly reduced in specimens containing liquid antibiotics.\n\nCONCLUSIONS: Adding vancomycin or amphotericin B antibiotic powder in distilled water before mixing with bone cement can significantly improve the efficiency of antibiotic release than can loading ALBC with the same dose of antibiotic powder. This simple and effective method for preparation of ALBCs can significantly improve the efficiency of antibiotic release in ALBCs. Cite this article: Bone Joint Res 2014;3:246-51.", "author" : [ { "dropping-particle" : "", "family" : "Chang", "given" : "Y H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tai", "given" : "C L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hsu", "given" : "H Y", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hsieh", "given" : "P H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lee", "given" : "M S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ueng", "given" : "S W N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone & joint research", "id" : "ITEM-2", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8" ] ] }, "page" : "246-51", "title" : "Liquid antibiotics in bone cement: an effective way to improve the efficiency of antibiotic release in antibiotic loaded bone cement.", "type" : "article-journal", "volume" : "3" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[52,53]", "plainTextFormattedCitation" : "[52,53]", "previouslyFormattedCitation" : "[52,53]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[52,53] . Newer composite systems also offer osteoinductive and osteoconductive propertiesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.bioeng.2007.08.001", "ISSN" : "1389-0344", "PMID" : "17869175", "abstract" : "In order to prevent the increasing frequency of per-operative infections, bioceramics can be loaded with anti-bacterial agents, which will release with respect to their chemical characteristics. A novel hydroxyapatite (HA) was elaborated with specific internal porosities for using as a bone-bioactive antibiotic (ATB) carrier material. UV spectrophotometry and bacteria inhibition tests were performed for testing the ATB adsorption and the microbiological effectiveness after loading with different antibiotics. The impregnation time, ATB impregnating concentration, impregnation condition and other factors, which might influence the ATB loading effect, were studied by exposure to different releasing solvents and different pathogenic bacteria: Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli. It clearly showed that the facility of ATB loading on this porous HA is even possible just under simple non-vacuum impregnation conditions in a not-so-long impregnating interval. The results also showed that, for all three types of ATB (vancomycin, ciprofloxacin and gentamicin), adsorbed amount on the micro-porous HA were hugely higher than that on dense HA. The micro-porosity of test HA had also significantly prolonged the release time of antibiotics even under mimic physiological conditions. Furthermore, it also has primarily proved by a pilot test that the antibacterial efficiency of crude micro-porous HA could be further significantly improved by other methods of functionalization such as cold plasma technique.", "author" : [ { "dropping-particle" : "", "family" : "Chai", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hornez", "given" : "J-C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Blanchemain", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Neut", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Descamps", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hildebrand", "given" : "H F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Biomolecular engineering", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2007", "11" ] ] }, "page" : "510-4", "title" : "Antibacterial activation of hydroxyapatite (HA) with controlled porosity by different antibiotics.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[54]", "plainTextFormattedCitation" : "[54]", "previouslyFormattedCitation" : "[54]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[54]. However with a paucity of in vivo evidence their clinical effectiveness is difficult to evaluate. (c) Debridement of Dead BoneFollowing intramedullary reaming and nail insertion the inner 1/3 to 2/3rds of the cortex loses perfusion because the endosteal circulation is destroyed and bone marrow blocks the intercortical canalsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0300-8827", "PMID" : "4192328", "author" : [ { "dropping-particle" : "", "family" : "Danckwardt-Lilliestr\u00f6m", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta orthopaedica Scandinavica. Supplementum", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "1969", "1" ] ] }, "page" : "1-153", "title" : "Reaming of the medullary cavity and its effect on diaphyseal bone. A fluorochromic, microangiographic and histologic study on the rabbit tibia and dog femur.", "type" : "article-journal", "volume" : "128" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0936-8051", "PMID" : "2073449", "abstract" : "Medullary nails have only been used with reluctance in the treatment of open fractures since reaming interferes with the cortical circulation. The technique of interlocking offers the interesting possibility of inserting a relatively stiff nail which does not necessarily require reaming. The effects of reaming prior to nail insertion upon the cortical circulation was investigated in the canine tibia. Intravital staining with procion red was used to trace areas of disturbed circulation. Nail insertion without reaming provided clear advantages for the bone's blood supply, while reaming disturbed perfusion in two-thirds of the cortical area and regionally extended through the entire thickness of the cortex. The disturbance without reaming was limited to the inner layer of the cortex and involved only one-third of the cortical cross-section.", "author" : [ { "dropping-particle" : "", "family" : "Klein", "given" : "M P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rahn", "given" : "B A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frigg", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kessler", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Perren", "given" : "S M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of orthopaedic and trauma surgery", "id" : "ITEM-2", "issue" : "6", "issued" : { "date-parts" : [ [ "1990", "1" ] ] }, "page" : "314-6", "title" : "Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia.", "type" : "article-journal", "volume" : "109" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "0001-6470", "PMID" : "8498187", "abstract" : "We examined the acute effects of increasing degree of intramedullary reaming on bone blood flow in 27 male Wistar rats by use of the microsphere method. A marginal reduction in total bone and cortical bone blood flow was seen when the femoral canal was reamed to a diameter smaller than the medullary cavity (1.5 mm). Reaming equal to the antero-posterior diameter (1.8 mm) halved total bone flow and reduced cortical blood flow by one third. Reaming equal to the transverse diameter (2.1 mm) reduced total bone flow to one third and cortical bone flow by one third. Intramedullary reaming of the tibia to 1.5 mm reduced total blood flow about 50 percent whereas cortical flow in the proximal half was unchanged. We conclude that modest intramedullary reaming has little effect on total and cortical blood flows, whereas reaming which involves destruction of the endosteal cortex reduces both total bone and cortical blood flows.", "author" : [ { "dropping-particle" : "", "family" : "Grundnes", "given" : "O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reiker\u00e5s", "given" : "O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta orthopaedica Scandinavica", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "1993", "4" ] ] }, "page" : "203-6", "title" : "Acute effects of intramedullary reaming on bone blood flow in rats.", "type" : "article-journal", "volume" : "64" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[55\u201357]", "plainTextFormattedCitation" : "[55\u201357]", "previouslyFormattedCitation" : "[55\u201357]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[55–57]. There is then a reactive increase in periosteal blood flow in order to maintain circulation in the cortical bedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "7744943", "abstract" : "The tibial nutrient artery supplies 62% of cortical blood flow in the diaphysis and normal blood flow is centrifugal (Willans 1987). Intramedullary reaming destroys the nutrient artery and injures the endosteal surface of the cortex. Trueta (1974) suggested that the direction of blood flow can reverse from centrifugal to centripetal after loss of the endosteal supply. We examined this hypothesis by measuring cortical and periosteal blood flow after intramedullary reaming of the tibia in eight sheep, using 57Co radiolabelled microspheres. The unreamed contralateral tibiae served as a control group. Thirty minutes after reaming there was no significant change in cortical blood flow, but a sixfold increase in the periosteal flow. Our study confirms Trueta's hypothesis; after trauma or in other pathological states, flow can become centripetal.", "author" : [ { "dropping-particle" : "", "family" : "Reichert", "given" : "I L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCarthy", "given" : "I D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hughes", "given" : "S P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1995", "5" ] ] }, "page" : "490-3", "title" : "The acute vascular response to intramedullary reaming. Microsphere estimation of blood flow in the intact ovine tibia.", "type" : "article-journal", "volume" : "77" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0009-921X", "PMID" : "657634", "abstract" : "The immediate effects of surgical dissection on regional bone blood flow were studied using the hydrogen washout technique and the results were compared in mature and immature rabbits. Epiphyseal circulation in young animals was eliminated by stripping the epiphyseal periosteum, and even in mature rabbits epiphyseal blood flow was markedly reduced by periosteal stripping. This suggests that after skeletal maturity blood supply crossing from the metaphysis into the epiphysis is limited. The blood flow rate was not altered by wide reaming of the epiphyseal center in either young or old animals. The rates of bone blood flow in the metaphysis and diaphysis were not altered by separate periosteal stripping or medullary reaming in either age group. Combined reaming and stripping eliminated blood flow in the diaphyseal cortical bone, but in the metaphysis fairly rapid blood flow remained even after reaming and periosteal stripping were done. These findings suggest that arterial supply and venous drainage traverse both endosteal and periosteal surfaces, and either system is capable of sustaining adequate bone tissue circulation.", "author" : [ { "dropping-particle" : "", "family" : "Whiteside", "given" : "L A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ogata", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lesker", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reynolds", "given" : "F C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-2", "issue" : "131", "issued" : { "date-parts" : [ [ "0", "1" ] ] }, "page" : "266-72", "title" : "The acute effects of periosteal stripping and medullary reaming on regional bone blood flow.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[58,59]", "plainTextFormattedCitation" : "[58,59]", "previouslyFormattedCitation" : "[58,59]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[58,59], converting the usual centrifugal flow of arterial blood to a centripetal dominant system. However, there is likely to be a cylinder of dead bone of varying thickness surrounding the intramedullary nail, which needs to be removed. This is achieved by sequential reaming from original nail size in 0.5mm diameter increments, until there is no fibrous membrane and no sclerotic white reaming debris. On the final reamer there should only be bony fragments with a healthy appearance. This will be approximately 1 to 2 mm greater than the largest reamer used previously. More recently the Reamer Irrigator Aspirator (RIA) system has been used to perform this intramedullary debridementADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.96B6.32244", "ISSN" : "2049-4408", "PMID" : "24891579", "abstract" : "Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer-Irrigator-Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny-Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.", "author" : [ { "dropping-particle" : "", "family" : "Kanakaris", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gudipati", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tosounidis", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harwood", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Britten", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2014", "6" ] ] }, "page" : "783-8", "title" : "The treatment of intramedullary osteomyelitis of the femur and tibia using the Reamer-Irrigator-Aspirator system and antibiotic cement rods.", "type" : "article-journal", "volume" : "96-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[60]", "plainTextFormattedCitation" : "[60]", "previouslyFormattedCitation" : "[60]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[60].As the remaining cortex is entirely dependent on the periosteum for its survival it is crucial to preserve the periosteal blood flow. In canine and lapine tibia studiesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-921X", "PMID" : "4609655", "author" : [ { "dropping-particle" : "", "family" : "Rhinelander", "given" : "F W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-1", "issue" : "105", "issued" : { "date-parts" : [ [ "0", "1" ] ] }, "page" : "34-81", "title" : "Tibial blood supply in relation to fracture healing.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[61]", "plainTextFormattedCitation" : "[61]", "previouslyFormattedCitation" : "[61]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[61], after 4-6 weeks the endosteal blood vessels were shown to have reformed, however in these early stages after intramedullary reaming it is vital to avoid any stripping of the remaining periosteum, such as might occur during plating or injudicious simultaneous open debridement.(d) Reconstitution of bone.It is important to consider the bone loss following debridement by its anatomical location in the bone and the extent of the defect in terms of the length of bone involved and whether the defect comprises partial or segmental circumferential loss. Segmental defects of greater than 2 cm are unlikely to heal spontaneously following skeletal stabilisation alone. Those involving less than 50% of the circumference can heal spontaneously but often require additional treatment to restore normal volume and strengthADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.87B2.15874", "ISSN" : "0301-620X", "author" : [ { "dropping-particle" : "", "family" : "Keating", "given" : "J. F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery - British Volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2005", "2", "1" ] ] }, "page" : "142-150", "title" : "The management of fractures with bone loss", "type" : "article-journal", "volume" : "87-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[62]", "plainTextFormattedCitation" : "[62]", "previouslyFormattedCitation" : "[62]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[62]. For larger defects bone grafting with or without induced membranes or bone transport are the main techniques. In deciding which technique to employ it is important to consider the size of the defect, associated treatment time, complications, requirement for further surgery and patient impactADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2016.01.023", "ISSN" : "00201383", "author" : [ { "dropping-particle" : "V.", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2016", "2" ] ] }, "page" : "291-292", "title" : "Treatment of bone defects: Bone transport or the induced membrane technique?", "type" : "article-journal", "volume" : "47" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[30]", "plainTextFormattedCitation" : "[30]", "previouslyFormattedCitation" : "[30]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[30].(3) Alternative Fixation modalities (Table. 1)(a) PlatingPlating is technically difficult in situations with infection and subsequent bone loss. In the presence of overt infection the plate acts as a nidus for biofilm formation. Extensive exposure may be required if there is a segmental defect to bridge resulting in significant periosteal stripping. The presence of segmental defects will compromise the stability of plate fixation. Plating is biomechanically unfavourable in the presence of a defect due to cantilever loading. New designs of plates, such as locking compression plates and minimally invasive systems overcome the soft tissue and biomechanical issues. Lengthening of the bone is much more difficult when a plate has been used for fixation. A plate spanning a segmental defect will prevent use of distraction osteogenesis or segmental bone transport. Therefore, plates are seldom the treatment of choice in infected diaphyseal fractures of the lower limb, but they continue to be useful for covertly infected nonunions of lower limb metaphysesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2106/jbjs.f.00742", "ISSN" : "0021-9355", "author" : [ { "dropping-particle" : "", "family" : "Brinker", "given" : "M R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "D P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-American Volume", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 33\nBrinker, Mark R. O'Connor, Daniel P.\n45", "page" : "177-188", "title" : "Exchange nailing of ununited fractures", "type" : "article-journal", "volume" : "89A" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26]", "plainTextFormattedCitation" : "[26]", "previouslyFormattedCitation" : "[26]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26] and humeralADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0890-5339", "PMID" : "8892150", "abstract" : "We reviewed 21 cases of humeral nonunion following the failure of \"locking\" humeral nails. The nails had been inserted as the primary operative procedure following humeral fracture in fifteen cases or after the failure of closed treatment in six cases. Reconstruction after the failure of these implants was complicated by poor bone stock and difficulty in achieving union. Although technically difficult, open reduction and internal fixation with plating and bone grafting (successful in nine of nine cases) was more consistent than exchange nailing (successful in four of 10 cases) in achieving union (p = 0.01). Two patients refused further surgical intervention. The degree of bone loss associated with a loose nail, the lack of success of exchange nailing, and the insertion site morbidity associated with humeral nail removal differentiate these nonunions from similar lower extremity problems. The degree of bone loss following failed locking nailing of the humerus is a major concern, and exchange nailing alone may not be an acceptable option to deal with this problem.", "author" : [ { "dropping-particle" : "", "family" : "McKee", "given" : "M D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Miranda", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riemer", "given" : "B L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Blasier", "given" : "R B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Redmond", "given" : "B J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sims", "given" : "S H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Waddell", "given" : "J P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jupiter", "given" : "J B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "1996", "1" ] ] }, "page" : "492-9", "title" : "Management of humeral nonunion after the failure of locking intramedullary nails.", "type" : "article-journal", "volume" : "10" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[25]", "plainTextFormattedCitation" : "[25]", "previouslyFormattedCitation" : "[25]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[25] fractures.Plating with or without bone grafting is the mainstay of definitive fixation for metaphyseal nonunions in the humerus and femur. However, exchange nailing can be used in the femur and tibia if there is sufficient metaphysis to engage a locking nail. (b) External FixationExternal fixation is a versatile method of treating nonunions, particularly in the presence of infection and bone loss and may be deployed in almost any location. Circular frames such as the Ilizarov are useful with extensive defects following debridement, particularly if distraction osteogenesis is being planned, or if there is an additional deformity requiring correction. The use of fine wires limits the surface area for bacterial adherence and biofilm formation. Shortening of the bone can be used to facilitate closure of soft tissue defectsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "11476302", "abstract" : "Z-plasty is used to lengthen scars and wounds. We describe the use of a modified technique to shorten wounds in ten consecutive patients undergoing acute shortening of a limb as part of an Ilizarov procedure. The modified technique gave good exposure, easy closure of the wound and fewer problems with healing than standard incisions.", "author" : [ { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Andrews", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giele", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2001", "7" ] ] }, "page" : "668-71", "title" : "Skin closure after acute shortening.", "type" : "article-journal", "volume" : "83" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[63]", "plainTextFormattedCitation" : "[63]", "previouslyFormattedCitation" : "[63]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[63], with the frame being subsequently used to restore length. External fixators can be used in the lower limb in conjunction with intramedullary nailing for bone transport. Frames have the advantage that they can be used in any location including periarticular defects with short juxta-articular segments. They can also be used to lengthen and transport bone, and correct deformity. As with other methods, external fixation has specific drawbacks. It may not be possible to remove the frame for many months and pin-track infections may require urgent medical or surgical treatmentADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.97B9.35626", "ISSN" : "2049-4408", "PMID" : "26330600", "abstract" : "External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur. We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment. Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagnosis and aggressive treatment are required in order to obtain a satisfactory outcome.", "author" : [ { "dropping-particle" : "", "family" : "Jauregui", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bor", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thakral", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Standard", "given" : "S C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Paley", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Herzenberg", "given" : "J E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2015", "9" ] ] }, "page" : "1296-300", "title" : "Life- and limb-threatening infections following the use of an external fixator.", "type" : "article-journal", "volume" : "97-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[64]", "plainTextFormattedCitation" : "[64]", "previouslyFormattedCitation" : "[64]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[64]. This is particularly the case in the femur and humerus. Fine-wire fixators applied too close to joints, particularly the knee, can result in septic arthritisADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0890-5339", "PMID" : "9553864", "abstract" : "OBJECTIVES: To observe the incidence and clinical presentation of infection in periarticular fractures of the tibia and femur treated with tensioned wire external fixators.\n\nDESIGN: Prospective cohort study.\n\nSETTING: Level One Trauma Center in urban community. Single surgeon.\n\nPATIENTS: One hundred thirty-five patients with 145 fractures: seventy tibial plateau, fifty-six pilon, and nineteen distal femur. Five-year treatment period, 1991 to 1995.\n\nMAIN OUTCOME MEASUREMENTS: The incidence of infection was evaluated.\n\nRESULTS: Nineteen of 145 fractures (13 percent) were complicated by infection. Infections presented as pin tract inflammation requiring intravenous antibiotics (seven), deep infection requiring debridement and removal (five), septic arthritis (three), deep fracture infection (three), and necrotizing fasciitis (one).\n\nCONCLUSIONS: Infection is a common complication of juxtaarticular fractures treated with tensioned wire fixators. Excellent pin care is required. Aggressive management of infections with intravenous antibiotics and debridement will resolve infections occurring in patients treated with tensioned wire fixators. Septic arthritis is associated with wires placed less than one centimeter from the subchondral bone. Deep infection is associated with insidious swelling and excessive proliferative callus. Wire infections increase with prolonged frame time.", "author" : [ { "dropping-particle" : "", "family" : "Hutson", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zych", "given" : "G A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "0", "1" ] ] }, "page" : "214-8", "title" : "Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators.", "type" : "article-journal", "volume" : "12" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[65]", "plainTextFormattedCitation" : "[65]", "previouslyFormattedCitation" : "[65]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[65]. Compliance with frames when they are in place for long periods can be a problemADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.87B2.15874", "ISSN" : "0301-620X", "author" : [ { "dropping-particle" : "", "family" : "Keating", "given" : "J. F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery - British Volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2005", "2", "1" ] ] }, "page" : "142-150", "title" : "The management of fractures with bone loss", "type" : "article-journal", "volume" : "87-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[62]", "plainTextFormattedCitation" : "[62]", "previouslyFormattedCitation" : "[62]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[62]. It has been suggested that use of circular frame should be reserved for infected nonunions in the proximal and distal metaphysis of the tibiaADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-921X", "PMID" : "10611886", "abstract" : "The treatment of infected nonunited fractures of the tibia using the techniques of Ilizarov was compared with autogenous cancellous bone graft application under a well vascularized soft tissue envelope. There were 10 patients in the Ilizarov group and 17 in the bone graft group. Soft tissue coverage with a free vascularized or a rotational muscle flap was used more frequently among the patients having bone graft (71%) than the Ilizarov group (30%). All 27 patients had bony defects (average, 3.7 cm; range, 1-18 cm). At an average followup of 6 years, 26 patients had a functional limb, and one patient (Ilizarov group) ultimately required a below knee amputation. Three patients in each group required a second plate and bone graft procedure to gain union. Infection persisted in four patients (all in the Ilizarov group). If a well vascularized soft tissue envelope is present (particularly after flap coverage), bone grafting procedures are safe and efficacious. The Ilizarov technique may be best suited for the treatment of very proximal or distal metaphyseal nonunions and nonunions associated with large leg length discrepancies.", "author" : [ { "dropping-particle" : "", "family" : "Ring", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jupiter", "given" : "J B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gan", "given" : "B S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Israeli", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yaremchuk", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-1", "issue" : "369", "issued" : { "date-parts" : [ [ "1999", "12" ] ] }, "page" : "302-11", "title" : "Infected nonunion of the tibia.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[66]", "plainTextFormattedCitation" : "[66]", "previouslyFormattedCitation" : "[66]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[66], large bone defects in the tibia diaphysis (>6cm)ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-921X", "PMID" : "10611886", "abstract" : "The treatment of infected nonunited fractures of the tibia using the techniques of Ilizarov was compared with autogenous cancellous bone graft application under a well vascularized soft tissue envelope. There were 10 patients in the Ilizarov group and 17 in the bone graft group. Soft tissue coverage with a free vascularized or a rotational muscle flap was used more frequently among the patients having bone graft (71%) than the Ilizarov group (30%). All 27 patients had bony defects (average, 3.7 cm; range, 1-18 cm). At an average followup of 6 years, 26 patients had a functional limb, and one patient (Ilizarov group) ultimately required a below knee amputation. Three patients in each group required a second plate and bone graft procedure to gain union. Infection persisted in four patients (all in the Ilizarov group). If a well vascularized soft tissue envelope is present (particularly after flap coverage), bone grafting procedures are safe and efficacious. The Ilizarov technique may be best suited for the treatment of very proximal or distal metaphyseal nonunions and nonunions associated with large leg length discrepancies.", "author" : [ { "dropping-particle" : "", "family" : "Ring", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jupiter", "given" : "J B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gan", "given" : "B S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Israeli", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yaremchuk", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-1", "issue" : "369", "issued" : { "date-parts" : [ [ "1999", "12" ] ] }, "page" : "302-11", "title" : "Infected nonunion of the tibia.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[66]", "plainTextFormattedCitation" : "[66]", "previouslyFormattedCitation" : "[66]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[66], and the distal humerusADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BOT.0b013e318032c4d8", "ISSN" : "0890-5339", "PMID" : "17473754", "abstract" : "OBJECTIVE: To report the functional outcomes of Ilizarov treatment of infected nonunion of the distal humerus.\n\nDESIGN: Prospective case series.\n\nSETTING: Tertiary referral center.\n\nPATIENTS: Between July 1998 and August 2003, 6 consecutive patients (age 33 to 73 years) were referred to us with an infected nonunion of the distal humerus following failure of open reduction and internal fixation. The average time from initial injury to presentation with the nonunion was 27 months (range, 6 to 99 months). The average number of prior surgeries was 2.8 (range, 1 to 4).\n\nINTERVENTION: Hardware removal, ulnar nerve neurolysis, 1 stage debridement, autogenous bone grafting, and application of an Ilizarov external fixator with acute compression in the operating room followed by slow gradual compression (0.25-0.50 mm per day) for several weeks postoperatively.\n\nMEASUREMENTS: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; SF-12 Physical Component Scale (PCS); Brief Pain Inventory; quality-adjusted life years.\n\nRESULTS: All patients attained bony union. One patient refractured 3 weeks after removal of the external fixator following a fall and ultimately underwent total elbow arthroplasty. At an average follow-up of 4.1 years (range, 2 to 7 years), none of the remaining 5 patients had undergone any additional surgery on their arm and all were free of infection. For these 5 patients, significant improvements were seen in standardized DASH scores (42% initially to 78% at follow-up, P = 0.017), worst pain intensity ratings (5.4 initially to 0.8 at follow-up, P = 0.007), and SF-12 PCS scores (37 initially to 44 at follow-up, P = 0.041). On average, the pretreatment to posttreatment improvement was equivalent to 3.8 quality-adjusted life years.\n\nCONCLUSIONS: Ilizarov treatment of infected distal humeral nonunions that have failed internal fixation restores function, decreases pain, and improves quality of life. The Ilizarov method should be considered a primary treatment option for this disabling and difficult clinical problem.", "author" : [ { "dropping-particle" : "", "family" : "Brinker", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "Daniel P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crouch", "given" : "C Craig", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mehlhoff", "given" : "Thomas L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bennett", "given" : "James B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2007", "3" ] ] }, "page" : "178-84", "title" : "Ilizarov treatment of infected nonunions of the distal humerus after failure of internal fixation: an outcomes study.", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[67]", "plainTextFormattedCitation" : "[67]", "previouslyFormattedCitation" : "[67]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[67]Ilizarov treatment has been found to be associated with union rates close to 100% in the management of infected diaphyseal non-unions of the tibiaADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.5812/atr.11300", "ISSN" : "2251-953X", "PMID" : "24396797", "abstract" : "BACKGROUND: The Ilizarov technique has been used in the UK for the last 20 years in the management of infected non-union of long bones. This method uses fine wires inserted percutaneously which are attached and tensioned to provide a strong frame construct. The majority of tibial and femoral non unions can be treated successfully by internal fixation. However, an infected non-union of the tibia can prove a difficult problem. The Ilizarov method can prove useful for treating these complex injuries.\n\nOBJECTIVES: To assess whether a new limb reconstruction centre in the UK has comparable results.\n\nPATIENTS AND METHODS: Twelve patients (10 M: 2 F; Avg age 43.3 years) who had an infected tibial non-union between March 2009 and August 2010 treated with the Ilizarov technique. Intervention method was Ilizarov technique and main outcome measures include functional and radiological outcomes assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analogue Pain scores.\n\nRESULTS: All twelve patients united. None required amputation. Mean time to union was 46 weeks (range 24 - 70/median 50). The average follow up time was 62 weeks (39 - 164/ median 59). According to the ASAMI score bone/radiological results ten were classed as excellent with the remainder being good. Functionally six were graded as excellent, four as good and two as poor. The average AOFAS score was 83/100 (70 - 90) and pain visual analogue scale (VAS) was two.\n\nCONCLUSIONS: Our results in terms of ASAMI scores are comparable with the published literature. Furthermore, our return to work is better than most European studies (63%). All our patients said they would have the procedure again. We attribute this success partly to the multidisciplinary approach. We recommend early referral to a dedicated unit if there is any evidence of a non-union.", "author" : [ { "dropping-particle" : "", "family" : "Shahid", "given" : "Mohammad", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hussain", "given" : "Abid", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bridgeman", "given" : "Phillipa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bose", "given" : "Deepa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of trauma research", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "8" ] ] }, "page" : "71-5", "title" : "Clinical outcomes of the Ilizarov method after an infected tibial non union.", "type" : "article-journal", "volume" : "2" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Venkatesh Gupta", "given" : "S.K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Govindappa", "given" : "C.V.S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rakesh Reddy", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Open access Orthopaedics", "id" : "ITEM-2", "issue" : "4", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "1-6", "title" : "Treatment of infective non-union of diaphyseal fractures with Ilizarov external fixation.", "type" : "article-journal", "volume" : "2" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/j.injury.2009.09.013", "ISSN" : "0020-1383", "author" : [ { "dropping-particle" : "", "family" : "Megas", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saridis", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kouzelis", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kallivokas", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mylonas", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tyllianakis", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury-International Journal of the Care of the Injured", "genre" : "JOUR", "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "note" : "Times Cited: 5\nMegas, Panagiotis Saridis, Alkis Kouzelis, Antonis Kallivokas, Alkiviadis Mylonas, Spyros Tyllianakis, Minos\n9\nSi", "page" : "294-299", "title" : "The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method", "type" : "article-journal", "volume" : "41" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[68\u201370]", "plainTextFormattedCitation" : "[68\u201370]", "previouslyFormattedCitation" : "[68\u201370]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[68–70]. Studies of Ilizarov frames using monfocal and bifocal techniques to treat infected nonunions with and without bone defects of the tibia report union rates between 85-100%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1186/1752-2897-2-6", "ISSN" : "1752-2897", "PMID" : "18651977", "abstract" : "BACKGROUND: Infected non-union of long bones is a problem in the developing countries. Persistent infection, deformity, shortening, bone loss, joint stiffness and disability complicate the non-union. Secondary procedures are often required for correction of bone defects and deformity. Ilizarov method addresses all the above problems simultaneously and offers a panacea for infected non-unions. The stability of the fixation and provision for bone transport allows bridging of bone defects, limb lengthening, early weight bearing ambulation and joint mobilisation.\n\nAIM OF THE STUDY: To know the suitability of this procedure in recalcitrant infected tibial non-unions in the Indian population and the influence of socio-economic factors in the functional outcome.\n\nMETHOD OF STUDY: This was a 3-year prospective study in 22 consecutive patients with an average follow up of 13 months following fracture union. The results were analysed using the ASAMI scoring system.\n\nRESULTS: Of 22 patients in the study, 13 patients who underwent external bone transport, had an average bone gap of 4 cms [2-11 cms] with an average duration of fixation of 9.3 months [6.5-13 months]. There were 4 excellent, 3 good, 4 fair and 2 poor bony results and 1 excellent, 3 good, 6 fair and 2 poor results. 1 patient was lost for follow up at final functional analysis. 9 patients who underwent internal bone transport had an average bone gap of 5.4 cms [1.5-9 cms] with an average duration of fixation of 8.5 months [4-11 months]. There were 3 good 4 fair and 2 poor bony results and 1 good, 3 fair, and 2 poor functional results. Good to excellent results were witnessed in well-motivated patients with adequate social and financial support. Patients with fair to poor results preferred amputation to limb salvage despite the fact that they retained their limbs.\n\nCONCLUSION: Treatment of infected non-unions of Tibia with Ilizarov ring fixation is effective but for optimal results the treatment needs to be individualised by the treating surgeon with due consideration of the socio-economic factors.", "author" : [ { "dropping-particle" : "", "family" : "Madhusudhan", "given" : "Thayur R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ramesh", "given" : "Balasundaram", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Manjunath", "given" : "Ks", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shah", "given" : "Harshad M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sundaresh", "given" : "Dabir C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Krishnappa", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of trauma management & outcomes", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2008", "1" ] ] }, "page" : "6", "title" : "Outcomes of Ilizarov ring fixation in recalcitrant infected tibial non-unions - a prospective study.", "type" : "article-journal", "volume" : "2" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0009-921X", "PMID" : "10611886", "abstract" : "The treatment of infected nonunited fractures of the tibia using the techniques of Ilizarov was compared with autogenous cancellous bone graft application under a well vascularized soft tissue envelope. There were 10 patients in the Ilizarov group and 17 in the bone graft group. Soft tissue coverage with a free vascularized or a rotational muscle flap was used more frequently among the patients having bone graft (71%) than the Ilizarov group (30%). All 27 patients had bony defects (average, 3.7 cm; range, 1-18 cm). At an average followup of 6 years, 26 patients had a functional limb, and one patient (Ilizarov group) ultimately required a below knee amputation. Three patients in each group required a second plate and bone graft procedure to gain union. Infection persisted in four patients (all in the Ilizarov group). If a well vascularized soft tissue envelope is present (particularly after flap coverage), bone grafting procedures are safe and efficacious. The Ilizarov technique may be best suited for the treatment of very proximal or distal metaphyseal nonunions and nonunions associated with large leg length discrepancies.", "author" : [ { "dropping-particle" : "", "family" : "Ring", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jupiter", "given" : "J B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gan", "given" : "B S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Israeli", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yaremchuk", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-2", "issue" : "369", "issued" : { "date-parts" : [ [ "1999", "12" ] ] }, "page" : "302-11", "title" : "Infected nonunion of the tibia.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "0009-921X", "PMID" : "15021133", "abstract" : "The Ilizarov method based on compression-distraction and subperiostic corticotomy was used in 82 lower extremities. There were 45 tibial nonunions without a significant bone defect and 37 tibial nonunions with a bone defect that required radical removal of the necrotic bone and bone lengthening or bone transport. Bone healing was obtained in 39 of the 45 tibial nonunions without bone defect (mean bone healing, 5.4 months) and in all patients with bone defect (mean bone healing, 15 months for patients treated with bone transport) although secondary surgeries (autografting and tibial nails) were frequent (23 patients). Infection was eradicated in all patients after necrotic bone removal and bone transport. The final mean limb length discrepancy was 0.7 cm for the patients without a bone defect and 2.03 cm for the patients with a bone defect. In the patients in the bone transport group, residual axial deviation and residual limb shortening were common. Circular external fixation is a useful method to solve complex tibial nonunions in patients in whom internal devices and autografting have failed. Patients must be cooperative, and must understand the length of time the frame needs to be worn, and that complications are a probability.", "author" : [ { "dropping-particle" : "", "family" : "Garc\u00eda-Cimbrelo", "given" : "Eduardo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mart\u00ed-Gonz\u00e1lez", "given" : "Jos\u00e9 C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-3", "issue" : "419", "issued" : { "date-parts" : [ [ "2004", "2" ] ] }, "page" : "65-70", "title" : "Circular external fixation in tibial nonunions.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1302/0301-620X.97B6.33276", "ISSN" : "2049-4394", "abstract" : "Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation. Cite this article: Bone Joint J 2015; 97-B:814-17.", "author" : [ { "dropping-particle" : "", "family" : "Bose", "given" : "D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kugan", "given" : "R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stubbs", "given" : "D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McNally", "given" : "M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Bone & Joint Journal", "id" : "ITEM-4", "issue" : "6", "issued" : { "date-parts" : [ [ "2015", "6", "1" ] ] }, "page" : "814-817", "title" : "Management of infected nonunion of the long bones by a multidisciplinary team", "type" : "article-journal", "volume" : "97-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[66,71\u201373]", "plainTextFormattedCitation" : "[66,71\u201373]", "previouslyFormattedCitation" : "[66,71\u201373]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[66,71–73], however between 30-90% of tibial cases require secondary surgery. Union results are similar in the femur, ranging between 95-100%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1371/journal.pone.0141973", "ISSN" : "1932-6203", "PMID" : "26529606", "abstract" : "BACKGROUND: Infected nonunion of tibia and femur are common in clinical practice, however, the treatment of these diseases has still been a challenge for orthopaedic surgeons. Ilizarov methods can eradicate infection, compensate bone defects and promote the bone union through progressive bone histogenesis. The objective of this systematic review was to review current available studies reporting on Ilizarov methods in the treatment of infected nonunion of tibia and femur, and to perform meta-analysis of bone and functional results and complications to evaluate the efficacy of Ilizarov methods.\n\nMETHODS: A comprehensive literature search was performed from the SCI, PubMed, Cochrane Library; and Embase between January 1995 and August 2015. Some major data were statistically analyzed using weighted means based on the sample size in each study by SPSS 13.0, including number of patients, mean age, mean previous surgical procedures, mean bone defects, mean length of follow-up, bone union, complications per patient, external fixation time, and external fixation index(EFI). Bone results (excellent, good, fair and poor rate), functional results (excellent, good, fair and poor rate) and complications were analyzed by Stata 9.0.\n\nFINDINGS: A total of 590 patients from 24 studies were included in this systematic review. The average of bone union rate was 97.26% in all included studies. The poor rate in bone results and functional results was 8% (95%CI, 0.04-0.12; I2 = 44.1%, P = 0.065) and 10% (95%CI, 0.05-0.14; I2 = 34.7%, P = 0.121) in patients with infected nonunion of tibia and femur treated by Ilizarov methods. The rate of refracture, malunion, infectious recurrence, knee stiffness, amputation, limb edema and peroneal nerve palsy was respectively 4%, 7%, 5%, 12%, 4%, 13% and 13%.\n\nCONCLUSIONS: Our systematic review showed that the patients with infected nonunion of tibia and femur treated by Ilizarov methods had a low rate of poor bone and functional results. Therefore, Ilizarov methods may be a good choice for the treatment of infected nonunion of tibia and femur.", "author" : [ { "dropping-particle" : "", "family" : "Yin", "given" : "Peng", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ji", "given" : "Qiunan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Li", "given" : "Tongtong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Li", "given" : "Jiantao", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Li", "given" : "Zhirui", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Liu", "given" : "Jianheng", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wang", "given" : "Guoqi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wang", "given" : "Song", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zhang", "given" : "Lihai", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mao", "given" : "Zhi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tang", "given" : "Peifu", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "PloS one", "id" : "ITEM-1", "issue" : "11", "issued" : { "date-parts" : [ [ "2015", "1" ] ] }, "page" : "e0141973", "title" : "A Systematic Review and Meta-Analysis of Ilizarov Methods in the Treatment of Infected Nonunion of Tibia and Femur.", "type" : "article-journal", "volume" : "10" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/0301-620X.92B4.23475", "ISSN" : "0301-620X", "PMID" : "20357336", "abstract" : "We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistent pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.", "author" : [ { "dropping-particle" : "", "family" : "Blum", "given" : "A L L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "BongioVanni", "given" : "J C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Morgan", "given" : "S J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flierl", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reis", "given" : "F Baldy", "non-dropping-particle" : "dos", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-2", "issue" : "4", "issued" : { "date-parts" : [ [ "2010", "4", "1" ] ] }, "page" : "565-70", "title" : "Complications associated with distraction osteogenesis for infected nonunion of the femoral shaft in the presence of a bone defect: a retrospective series.", "type" : "article-journal", "volume" : "92" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "1022-5536", "PMID" : "17200527", "abstract" : "PURPOSE: To evaluate the treatment outcome of the modified Ilizarov technique in infected nonunion of the femur.\n\nMETHODS: Between 1989 and 2002, records of 20 patients with infected nonunion of the femur treated with the modified Ilizarov technique were retrospectively reviewed. The modified Ilizarov frame was fixed after necrectomy of the dead infected bone and tissues. A proximal or distal corticotomy was performed following biological principles. For regeneration of gap, segmental transport was performed in 11 patients with a gap of more than 5 cm; acute docking followed by lengthening at the corticotomy site was performed in 9 patients with a gap of smaller than 5 cm. Mobilisation was started early with active participation of the physical therapist and the patients. Bone and functional results were measured and complications were categorised according to the Association for the Study and Application of the Method of Ilizarov guidelines.\n\nRESULTS: The mean follow-up period was 62.8 months. Bony union and eradication of the infection was achieved in all patients except one who underwent amputation due to uncontrolled infection. Bone results were excellent in 13 patients, good in 4, fair in one, poor in one, and treatment failure (amputation) in one. Functional results were excellent in 3 patients, good in 9, fair in 3, poor in 4, and failure in one. A total of 71 complications occurred: 35 problems, 6 obstacles, and 30 true complications. The mean healing index was 38.3 day/cm (standard deviation, 1.6 day/cm).\n\nCONCLUSION: The Ilizarov technique is a good salvage operation for infected nonunion of the femur. Limb salvage is preferable to prosthesis if the limb is viable, adequately innervated and the patient is mentally and financially committed to save the limb.", "author" : [ { "dropping-particle" : "", "family" : "Krishnan", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pamecha", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patwa", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic surgery (Hong Kong)", "id" : "ITEM-3", "issue" : "3", "issued" : { "date-parts" : [ [ "2006", "12" ] ] }, "page" : "265-72", "title" : "Modified Ilizarov technique for infected nonunion of the femur: the principle of distraction-compression osteogenesis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1302/0301-620X.88B2.16976", "ISSN" : "0301-620X", "PMID" : "16434530", "abstract" : "We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight. The mean external fixation time was 309.8 days. According to Paley's grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.", "author" : [ { "dropping-particle" : "", "family" : "Saridis", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Panagiotopoulos", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tyllianakis", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Matzaroglou", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vandoros", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lambiris", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-4", "issue" : "2", "issued" : { "date-parts" : [ [ "2006", "2" ] ] }, "page" : "232-7", "title" : "The use of the Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss.", "type" : "article-journal", "volume" : "88" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "ISSN" : "0972-1177", "author" : [ { "dropping-particle" : "", "family" : "Arora", "given" : "RK", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JK Science : Journal of Medical Education & Research", "id" : "ITEM-5", "issue" : "1", "issued" : { "date-parts" : [ [ "2003", "1", "1" ] ] }, "page" : "22-25", "publisher" : "JK Science", "title" : "Usefulness of Ilizarov's Procedure in Infected Non-Union of Tibia and Femur", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] }, { "id" : "ITEM-6", "itemData" : { "ISSN" : "0020-1383", "PMID" : "10908744", "abstract" : "Thirty patients with infected non-union of long bones were treated with radical resection of the necrotic bone and bone transport or compression/distraction osteosynthesis. Non-union, infection, deformity, bone gap and shortening were all addressed simultaneously using the Ilizarov principles. There were 15 cases with bone loss ranging from 4 to 12 cm (median bone gap of 7 cm), 10 cases of stiff non-union (six of which had an associated deformity) and five cases of mobile non-union. The median time in the Ilizarov frame was 150 days. Median follow up time after frame removal was 23.5 months. Bone grafting at the docking site was only required in three cases (10%). There were three cases of refracture (10%) and three cases of recurrence of infection (10%). The bone result was excellent in 21 patients (70%), good in three (10%), fair in none (0%) and poor in six (20%). The functional results were excellent in eight patients (26.7%), good in 12 (40.0%), fair in three (10%) and poor in seven (23.3%). It is difficult to precisely define the indications for preservation and reconstruction of severe injuries. The surgical team has to take into account the length, disability, complications and cost of treatment. Patients must be aware of the limitations of functional results and the possible difficulty of return to work despite the reconstructive attempt.", "author" : [ { "dropping-particle" : "", "family" : "Maini", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chadha", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vishwanath", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kapoor", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mehtani", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dhaon", "given" : "B K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-6", "issue" : "7", "issued" : { "date-parts" : [ [ "2000", "9" ] ] }, "page" : "509-17", "title" : "The Ilizarov method in infected nonunion of fractures.", "type" : "article-journal", "volume" : "31" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[74\u201379]", "plainTextFormattedCitation" : "[74\u201379]", "previouslyFormattedCitation" : "[74\u201379]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[74–79]. However they are associated with a 55-100% rate of pin-track infectionADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.92B4.23475", "ISSN" : "0301-620X", "PMID" : "20357336", "abstract" : "We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistent pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.", "author" : [ { "dropping-particle" : "", "family" : "Blum", "given" : "A L L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "BongioVanni", "given" : "J C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Morgan", "given" : "S J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flierl", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reis", "given" : "F Baldy", "non-dropping-particle" : "dos", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2010", "4", "1" ] ] }, "page" : "565-70", "title" : "Complications associated with distraction osteogenesis for infected nonunion of the femoral shaft in the presence of a bone defect: a retrospective series.", "type" : "article-journal", "volume" : "92" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "1022-5536", "PMID" : "17200527", "abstract" : "PURPOSE: To evaluate the treatment outcome of the modified Ilizarov technique in infected nonunion of the femur.\n\nMETHODS: Between 1989 and 2002, records of 20 patients with infected nonunion of the femur treated with the modified Ilizarov technique were retrospectively reviewed. The modified Ilizarov frame was fixed after necrectomy of the dead infected bone and tissues. A proximal or distal corticotomy was performed following biological principles. For regeneration of gap, segmental transport was performed in 11 patients with a gap of more than 5 cm; acute docking followed by lengthening at the corticotomy site was performed in 9 patients with a gap of smaller than 5 cm. Mobilisation was started early with active participation of the physical therapist and the patients. Bone and functional results were measured and complications were categorised according to the Association for the Study and Application of the Method of Ilizarov guidelines.\n\nRESULTS: The mean follow-up period was 62.8 months. Bony union and eradication of the infection was achieved in all patients except one who underwent amputation due to uncontrolled infection. Bone results were excellent in 13 patients, good in 4, fair in one, poor in one, and treatment failure (amputation) in one. Functional results were excellent in 3 patients, good in 9, fair in 3, poor in 4, and failure in one. A total of 71 complications occurred: 35 problems, 6 obstacles, and 30 true complications. The mean healing index was 38.3 day/cm (standard deviation, 1.6 day/cm).\n\nCONCLUSION: The Ilizarov technique is a good salvage operation for infected nonunion of the femur. Limb salvage is preferable to prosthesis if the limb is viable, adequately innervated and the patient is mentally and financially committed to save the limb.", "author" : [ { "dropping-particle" : "", "family" : "Krishnan", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pamecha", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patwa", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic surgery (Hong Kong)", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2006", "12" ] ] }, "page" : "265-72", "title" : "Modified Ilizarov technique for infected nonunion of the femur: the principle of distraction-compression osteogenesis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1302/0301-620X.88B2.16976", "ISSN" : "0301-620X", "PMID" : "16434530", "abstract" : "We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight. The mean external fixation time was 309.8 days. According to Paley's grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.", "author" : [ { "dropping-particle" : "", "family" : "Saridis", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Panagiotopoulos", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tyllianakis", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Matzaroglou", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vandoros", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lambiris", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "2006", "2" ] ] }, "page" : "232-7", "title" : "The use of the Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss.", "type" : "article-journal", "volume" : "88" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[75\u201377]", "plainTextFormattedCitation" : "[75\u201377]", "previouslyFormattedCitation" : "[75\u201377]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[75–77], up to 70% malunionADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1022-5536", "PMID" : "17200527", "abstract" : "PURPOSE: To evaluate the treatment outcome of the modified Ilizarov technique in infected nonunion of the femur.\n\nMETHODS: Between 1989 and 2002, records of 20 patients with infected nonunion of the femur treated with the modified Ilizarov technique were retrospectively reviewed. The modified Ilizarov frame was fixed after necrectomy of the dead infected bone and tissues. A proximal or distal corticotomy was performed following biological principles. For regeneration of gap, segmental transport was performed in 11 patients with a gap of more than 5 cm; acute docking followed by lengthening at the corticotomy site was performed in 9 patients with a gap of smaller than 5 cm. Mobilisation was started early with active participation of the physical therapist and the patients. Bone and functional results were measured and complications were categorised according to the Association for the Study and Application of the Method of Ilizarov guidelines.\n\nRESULTS: The mean follow-up period was 62.8 months. Bony union and eradication of the infection was achieved in all patients except one who underwent amputation due to uncontrolled infection. Bone results were excellent in 13 patients, good in 4, fair in one, poor in one, and treatment failure (amputation) in one. Functional results were excellent in 3 patients, good in 9, fair in 3, poor in 4, and failure in one. A total of 71 complications occurred: 35 problems, 6 obstacles, and 30 true complications. The mean healing index was 38.3 day/cm (standard deviation, 1.6 day/cm).\n\nCONCLUSION: The Ilizarov technique is a good salvage operation for infected nonunion of the femur. Limb salvage is preferable to prosthesis if the limb is viable, adequately innervated and the patient is mentally and financially committed to save the limb.", "author" : [ { "dropping-particle" : "", "family" : "Krishnan", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pamecha", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patwa", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic surgery (Hong Kong)", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2006", "12" ] ] }, "page" : "265-72", "title" : "Modified Ilizarov technique for infected nonunion of the femur: the principle of distraction-compression osteogenesis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[76]", "plainTextFormattedCitation" : "[76]", "previouslyFormattedCitation" : "[76]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[76] and up to 30% requirement for bone graftingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.92B4.23475", "ISSN" : "0301-620X", "PMID" : "20357336", "abstract" : "We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistent pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.", "author" : [ { "dropping-particle" : "", "family" : "Blum", "given" : "A L L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "BongioVanni", "given" : "J C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Morgan", "given" : "S J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flierl", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reis", "given" : "F Baldy", "non-dropping-particle" : "dos", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2010", "4", "1" ] ] }, "page" : "565-70", "title" : "Complications associated with distraction osteogenesis for infected nonunion of the femoral shaft in the presence of a bone defect: a retrospective series.", "type" : "article-journal", "volume" : "92" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[75]", "plainTextFormattedCitation" : "[75]", "previouslyFormattedCitation" : "[75]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[75]. There are no studies in the literature reporting its use in infected humerus nonunions following IM nailing. Brinker et al reported a series of six patients with infected distal nonunion following plating, with all six going on to unite free of infection. (4) Treatment Strategies(a) Exchange nailing (i) Ability to suppress the infection to unionFor exchange nailing to be successful, it is necessary to eradicate or suppress the infection until union has occurred. To achieve this (as with single stage revision arthroplastyADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.95B11.32646", "ISSN" : "2049-4408", "PMID" : "24187359", "abstract" : "Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases. Looking carefully at current literature and guidelines for PJI treatment, there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach. A cemented one-stage exchange potentially offers certain advantages, mainly based on the need for only one operative procedure, reduced antibiotics and hospitalisation time. In order to fulfill a one-stage approach, there are obligatory pre-, peri- and post-operative details that need to be meticulously respected, and are described in detail. Essential pre-operative diagnostic testing is based on the joint aspiration with an exact identification of any bacteria. The presence of a positive bacterial culture and respective antibiogram are essential, to specify the antibiotics to be loaded to the bone cement, which allows a high local antibiotic elution directly at the surgical side. A specific antibiotic treatment plan is generated by a microbiologist. The surgical success relies on the complete removal of all pre-existing hardware, including cement and restrictors and an aggressive and complete debridement of any infected soft tissues and bone material. Post-operative systemic antibiotic administration is usually completed after only ten to 14 days.", "author" : [ { "dropping-particle" : "", "family" : "Gehrke", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zahar", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kendoff", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-1", "issue" : "11 Suppl A", "issued" : { "date-parts" : [ [ "2013", "11" ] ] }, "page" : "77-83", "title" : "One-stage exchange: it all began here.", "type" : "article-journal", "volume" : "95-B" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0301-620X", "PMID" : "7021561", "abstract" : "Exchange operation is recommended as the treatment of choice for most deep infections involving a total hip replacement. This revision arthroplasty comprises, in one stage, excision of soft tissue, removal of implant and cement, replacement with an appropriate implant using Palacos R acrylic cement loaded with an appropriate antibiotic and, more recently, systemic antibiotics. During our first 10 years without systemic antibiotics we have achieved an overall 77 per cent success rate from a first attempt in 583 patients and a 90 per cent success rate after subsequent exchange procedures. Morbidity is significant but acceptable. Success is defined as control of infection, no loosening, and useful function. The factors associated with failures include, in particular, specific infections (Pseudomonas group, Streptococcus group D, Proteus group, and Escherichia coli), delay in operation and inadequate antibiotic dosage in the cement.", "author" : [ { "dropping-particle" : "", "family" : "Buchholz", "given" : "H W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Elson", "given" : "R A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Engelbrecht", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lodenk\u00e4mper", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "R\u00f6ttger", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Siegel", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "1981", "1" ] ] }, "page" : "342-53", "title" : "Management of deep infection of total hip replacement.", "type" : "article-journal", "volume" : "63-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[80,81]", "plainTextFormattedCitation" : "[80,81]", "previouslyFormattedCitation" : "[80,81]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[80,81]) it is important to have identified the organism and for it to be sensitive to an antibiotic that can be delivered locally and/or for it to be sensitive to an oral agent that does not inhibit fracture repairADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2007.10.035", "ISSN" : "0020-1383", "PMID" : "18316083", "abstract" : "Bone healing is an extremely complex process which depends on the coordinated action of several cell lineages on a cascade of biological events, and has always been a major medical concern. The use of several drugs such as corticosteroids, chemotherapeutic agents, non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics, anticoagulants and drugs which reduce osteoclastic activity have been shown to affect bone healing. This review article presents our current understanding on this topic, focusing on data illustrating the effect of these drugs on fracture healing and bone regeneration.", "author" : [ { "dropping-particle" : "", "family" : "Pountos", "given" : "Ippokratis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Georgouli", "given" : "Theodora", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Blokhuis", "given" : "Taco J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pape", "given" : "Hans Chistoph", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2008", "4" ] ] }, "page" : "384-94", "title" : "Pharmacological agents and impairment of fracture healing: what is the evidence?", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1517/14740338.2011.589833", "ISSN" : "1744-764X", "PMID" : "21824037", "abstract" : "INTRODUCTION: Bone healing is a complex cascade of events that involves the proliferation and differentiation of osteoblastic cells under the influence of signals from growth factors, cytokines and mechanical loading. Several medications have been found to interact negatively with this process including cytostatics, NSAIDs and corticosteroids; however, the effect of antibiotics on bone repair processes remains obscure.\n\nAREAS COVERED: The authors offer a comprehensive review of the existing literature on the in vivo and in vitro effect of antibiotics on bone, bone cells and fracture healing. The authors describe the pharmacokinetic characteristics of antibiotics after parenteral administration as well as their levels when applied locally together with a delivery vehicle.\n\nEXPERT OPINION: The available experimental data and clinical evidence are rather limited to allow safe conclusions. In vitro studies indicate that high doses administered after systemic administration have little or no direct effect on bone cells. Further studies are desirable to define the effect of higher or prolonged concentrations on bone biology and especially that of high concentrations released by locally implanted antibiotic-delivery systems, that is, bone cement, spacers and beads.", "author" : [ { "dropping-particle" : "", "family" : "Pountos", "given" : "Ippokratis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Georgouli", "given" : "Theodora", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bird", "given" : "Howard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kontakis", "given" : "George", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Expert opinion on drug safety", "id" : "ITEM-2", "issue" : "6", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "935-45", "title" : "The effect of antibiotics on bone healing: current evidence.", "type" : "article-journal", "volume" : "10" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/S0736-0266(01)00022-5", "ISSN" : "0736-0266", "PMID" : "11562146", "abstract" : "We examined the effects of rifampicin on osteoblast-like cells derived from adult human bone in vitro. Cancellous bone was collected from five different individuals during elective orthopaedic operations and cultured in antibiotic-free media. Total DNA, 3H-thymidine incorporation and alkaline phosphatase (ALP) activity were measured after the cells were cultured for 4 days in media containing concentrations of rifampicin ranging from 0 to 1000 microg/ml. Mean total DNA was decreased at concentrations of 10 microg/ml and above in the cultures obtained from four out of five individuals but these decreases were significant in the cultures from only two individuals. 3H-thymidine incorporation, a more sensitive indicator of change in cell proliferation, and ALP activity were significantly decreased (P < 0.05) in all of the cultures containing 3 and 7 microg/ml, respectively. In the clinical setting, serum concentrations of rifampicin often exceed 10 microg/ml after systemic administration. The present study has shown that rifampicin, at these concentrations, can inhibit the proliferation of osteoblast-like cells in vitro. Further studies should be carried out to assess whether rifampicin is detrimental to the bone repair process in vivo.", "author" : [ { "dropping-particle" : "", "family" : "Isefuku", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Joyner", "given" : "C J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic research : official publication of the Orthopaedic Research Society", "id" : "ITEM-3", "issue" : "5", "issued" : { "date-parts" : [ [ "2001", "9" ] ] }, "page" : "950-4", "title" : "Toxic effect of rifampicin on human osteoblast-like cells.", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "ISSN" : "0890-5339", "PMID" : "12621263", "abstract" : "OBJECTIVE: To investigate the toxic effect of gentamicin at the high concentrations that can be achieved by local administration in the management of bone infection.\n\nDESIGN: Randomized, prospective study in cultured cells, with drug exposure duration of 4 days.\n\nSETTING: Cell culture in Dulbecco's modification of Eagle's minimal essential medium with supplements at 37 degrees C in air:CO2 (v:v, 95:5).\n\nMATERIALS: Human osteoblastlike cells derived from cancellous bone collected from four adult patients without systemic disease during total hip replacement were cultured in antibiotic-free medium for 4 weeks.\n\nINTERVENTION: The cultured cells were exposed to media containing various concentrations of gentamicin (0-1000 microg/mL) for 4 days.\n\nMAIN OUTCOME MEASUREMENTS: Alkaline phosphatase activity, total DNA, and 3H-thymidine incorporation.\n\nRESULT: Alkaline phosphatase activity was significantly decreased (p < 0.05) in all of the cultures at gentamicin concentrations of 100 microg/mL and above. 3H-thymidine incorporation was also decreased (p < 0.05) in three out of four cultures at 100 microg/mL and above. Total DNA was significantly decreased (p < 0.05) at 700 microg/mL and above.\n\nCONCLUSION: Gentamicin, at high concentrations, as achieved following topical application, inhibits cell proliferation in vitro and, therefore, may be detrimental to the repair process in vivo.", "author" : [ { "dropping-particle" : "", "family" : "Isefuku", "given" : "Shuji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Joyner", "given" : "Clive J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A Hamish R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-4", "issue" : "3", "issued" : { "date-parts" : [ [ "2003", "3" ] ] }, "page" : "212-6", "title" : "Gentamicin may have an adverse effect on osteogenesis.", "type" : "article-journal", "volume" : "17" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "DOI" : "10.1002/jor.1100160417", "ISSN" : "0736-0266", "PMID" : "9747794", "abstract" : "Locally applied antibiotic therapy is gaining popularity for the treatment of infections associated with open fractures and posttraumatic osteomyelitis. With use of local techniques, ciprofloxacin levels as high as 1,300 microg/ml, or over 200 times the bone levels achieved with intravenous administration, have been reported. To study the possible effects of ciprofloxacin on bone, osteoblast-like cells from the MG-63 human osteosarcoma cell line were studied. The cells were grown in antibiotic-free media and exposed to concentrations of ciprofloxacin at 0, 10, 100, 200, and 1,000 microg/ml to establish an initial dose-response curve. Media containing the appropriate dose of ciprofloxacin were changed every 24 hours. Cell number and [3H]thymidine incorporation per cell were determined at 0, 24, and 72 hours. A second dose-response curve was performed at concentrations of 0, 10, 20, 40, and 80 microg/ml. Three experiments, each with four observations, were performed. The results of this study demonstrated that ciprofloxacin caused significant decreases (p < 0.05) in cell number at 40 microg/ml at 24 hours and 20 microg/ml at 72 hours. [3H]thymidine incorporation per cell decreased significantly at levels of 80 microg/ml at 24 hours and 20 microg/ml at 72 hours. The authors conclude that reported local levels of ciprofloxacin seen in vivo inhibit the proliferation of human osteoblast-like cells in vitro.", "author" : [ { "dropping-particle" : "", "family" : "Miclau", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Edin", "given" : "M L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lester", "given" : "G E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lindsey", "given" : "R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dahners", "given" : "L E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic research : official publication of the Orthopaedic Research Society", "id" : "ITEM-5", "issue" : "4", "issued" : { "date-parts" : [ [ "1998", "7" ] ] }, "page" : "509-12", "title" : "Effect of ciprofloxacin on the proliferation of osteoblast-like MG-63 human osteosarcoma cells in vitro.", "type" : "article-journal", "volume" : "16" }, "uris" : [ "" ] }, { "id" : "ITEM-6", "itemData" : { "ISSN" : "0009-921X", "PMID" : "8981903", "abstract" : "The effect of cefazolin and vancomycin on osteoblast-like cells was studied. Cells from the MG-63 human osteosarcoma cell line were grown in antibiotic free media and exposed to concentrations of cefazolin and vancomycin at order of magnitude intervals between 0 and 10,000 microg/ml. For cefazolin, a second interval was performed between 100 and 1000 microg/ml to define toxic levels more accurately. Cell number and 3H-thymidine incorporation at 0, 24, and 72 hours were determined. The results of this study show that local levels of vancomycin of 1000 microg/ml and less have little or no effect on osteoblast replication, and concentrations of 10,000 microg/ml cause cell death. Concentrations of cefazolin of 100 microg/ml and less have little or no effect on osteoblast replication, 200 microg/ml significantly decrease cell replication, and 10,000 microg/ml cause cell death. The authors conclude that vancomycin is less toxic than is cefazolin to osteoblasts at higher concentrations and may be a better antibiotic for local administration in the treatment of similarly sensitive bacterial infections.", "author" : [ { "dropping-particle" : "", "family" : "Edin", "given" : "M L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Miclau", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lester", "given" : "G E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lindsey", "given" : "R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dahners", "given" : "L E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-6", "issue" : "333", "issued" : { "date-parts" : [ [ "1996", "12" ] ] }, "page" : "245-51", "title" : "Effect of cefazolin and vancomycin on osteoblasts in vitro.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[82\u201387]", "plainTextFormattedCitation" : "[82\u201387]", "previouslyFormattedCitation" : "[82\u201387]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[82–87] and that the patient can tolerate. To assess whether patients have the ability to progress to union, we evaluated whether there was periosteal callus on any of the cortices, bearing in mind that the amount of periosteal callus and it location will be substantially influenced not only by the nature of the initial injury but also by the way in which the fracture was previously treatedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.87B2.15874", "ISSN" : "0301-620X", "author" : [ { "dropping-particle" : "", "family" : "Keating", "given" : "J. F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery - British Volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2005", "2", "1" ] ] }, "page" : "142-150", "title" : "The management of fractures with bone loss", "type" : "article-journal", "volume" : "87-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[62]", "plainTextFormattedCitation" : "[62]", "previouslyFormattedCitation" : "[62]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[62].We examined a consecutive cohort of 20 femora and 35 tibiae undergoing exchange nailing for diaphyseal aseptic (n=38) and septic (n=17) nonunion at a single centre from 2003 to 2010. Of this cohort 49 nonunions had complete radiographic records (19 femora and 30 tibiae) allowing evaluation of the periosteal callusADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "abstract" : "The aim of this study was to determine whether the absence of periosteal reaction on plain radiographs was predictive of exchange nail failure in lower limb diaphyseal fracture non-unions. The study cohort comprised 46 patients with lower limb diaphyseal non-unions treated by exchange nail surgery. Multiple causes of non-union were found in 23 patients (50.0%) with infection present in 14 cases (30.4%). The main outcome measures were union, number of secondary fixation procedures and time to union. Periosteal reaction adjacent to the non-union site was present in 34 cases (73.9%) and absent in 12 cases (26.1%) at the time of exchange nailing. The median time to exchange nail from primary fixation was 7.7 months. Further exchange procedures were required in seven patients (20.6%) with periosteal reaction and in five patients (41.6%) with no periosteal reaction. There were no significant differences between groups (p>0.05). Union was ultimately achieved in 41 patients (97.6%). The overall median time to union was 9.2 months. Multi-regression analysis indicated that the absence of periosteal reaction on plain radiographs was predictive of failure, along with host factors, Gustilo and Anderson grade and infection (p <0.05). The absence of periosteal reaction at the fracture site was associated with 100% sensitivity and 91% specificity for exchange nail failure. Careful radiographic analysis of lower limb diaphyseal non-union should be undertaken before exchange nailing. The absence of periosteal reaction on plain radiographs is predictive of exchange nail failure.", "author" : [ { "dropping-particle" : "", "family" : "Tsang", "given" : "STJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mills", "given" : "Leanora Anne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baren", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frantzias", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "J F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A Hamish R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Unpublished work", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2016" ] ] }, "title" : "Absence of periosteal reaction is predictive of exchange nail failure for diaphyseal fracture non-union", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[88]", "plainTextFormattedCitation" : "[88]", "previouslyFormattedCitation" : "[88]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[88]. If the periosteal callus was absent from the fracture site on all 4 cortices (Fig. 1), there was a relative risk ratio (RRR) 5.00 (p=0.006) of exchange nail failure in septic nonunions. Receiver operator characteristic curve analysis (Fig. 2) of number of cortices with periosteal reaction for predicting exchange nail failure in both septic and aseptic cases found an area under the curve of 0.79 (95% confidence interval 0.675-0.904, p<0.0001). A summary of the curve cut-off co-ordinates for the infected cases is shown in Table.2. If there were no cortices with periosteal callus at the fracture site this had a positive predictive value 75% and negative predictive value 100% i.e. if none of the cortices had callus within 5 mm, of the fracture site, there was a 75% chance the patient would need 3 or more exchange nails to obtain union. Conversely if periosteal callus was present on at least one cortex within 5mm of the fracture site there was a 100% chance the fracture would unite following 1 or 2 exchange nail procedures.(ii) The techniqueExchange nailing for the treatment of an infected long bone nonunions involves removal of the current intramedullary nail, reaming of the medullary canal, and placement of an intramedullary nail that is larger in diameter than the removed nailADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "abstract" : "There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series.", "author" : [ { "dropping-particle" : "", "family" : "Court-Brown", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "J F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "M M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-British Volume", "genre" : "JOUR", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "1992" ] ] }, "note" : "From Duplicate 2 ( \n\n\n\n\n\n\n\n\nInfection after intramedullary nailing of the tibia. Incidence and protocol for management.\n\n\n\n\n\n\n\n\n- Courtbrown, C M; Keating, J F; McQueen, M M )\n\n\n\n\n\n\n\nTimes Cited: 80\n81", "page" : "770-774", "title" : "Infection after intramedullary nailing of the tibia. Incidence and protocol for management.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0301-620X", "abstract" : "Exchange nailing for failure of union after primary intramedullary nailing of the tibia is widely used but the indications and effectiveness have not been reported in detail. We have reviewed 33 cases of uninfected nonunion of the tibia treated by exchange nailing. This technique was successful without open bone grafting in all closed fractures and in open fractures of Gustilo types I, II and IIIa. The requirement for open bone grafting was reduced in type-IIIb fractures, but exchange nailing failed in type-IIIb fractures with significant bone loss. For these we recommend early open bone grafting. The most common complication was wound infection, seen more often than after primary nailing, We discuss our protocol for the use and timing of exchange nailing of all grades and types of tibial fracture.", "author" : [ { "dropping-particle" : "", "family" : "Courtbrown", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "J F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Christie", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "M M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Court-Brown", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-British Volume", "genre" : "JOUR", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "1995" ] ] }, "note" : "\n From Duplicate 2 ( \n \n \n Exchange intramedullary nailing. Its use in aseptic tibial nonunion.\n \n \n - Courtbrown, C M; Keating, J F; Christie, J; McQueen, M M )\n\n \n \nTimes Cited: 74\n81\n\n \n\n ", "page" : "407-411", "title" : "Exchange intramedullary nailing. Its use in aseptic tibial nonunion.", "type" : "article-journal", "volume" : "77B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[89,90]", "plainTextFormattedCitation" : "[89,90]", "previouslyFormattedCitation" : "[89,90]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[89,90] following debridement and irrigation. It provides stable fixation, allows bridging of long defects, and can be inserted with minimal soft tissue and periosteal disruptionADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.87B2.15874", "ISSN" : "0301-620X", "author" : [ { "dropping-particle" : "", "family" : "Keating", "given" : "J. F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery - British Volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2005", "2", "1" ] ] }, "page" : "142-150", "title" : "The management of fractures with bone loss", "type" : "article-journal", "volume" : "87-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[62]", "plainTextFormattedCitation" : "[62]", "previouslyFormattedCitation" : "[62]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[62]. The soft tissues can be readily accessed for further wound debridement and soft-tissue cover, and joints can be mobilised readily. It has been established that reaming of the medullary canal increases periosteal blood flow and stimulates periosteal new-bone formation,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0300-8827", "PMID" : "4192328", "author" : [ { "dropping-particle" : "", "family" : "Danckwardt-Lilliestr\u00f6m", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta orthopaedica Scandinavica. Supplementum", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "1969", "1" ] ] }, "page" : "1-153", "title" : "Reaming of the medullary cavity and its effect on diaphyseal bone. A fluorochromic, microangiographic and histologic study on the rabbit tibia and dog femur.", "type" : "article-journal", "volume" : "128" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[55]", "plainTextFormattedCitation" : "[55]", "previouslyFormattedCitation" : "[55]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[55] which in turn aids in healing of the nonunion. However in order for the above process to occur the bone and periosteum adjacent to the fracture site must be biologically active. It is therefore crucial to preserve the periosteal blood supply when managing infected nonunions following IM nailingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-921X", "PMID" : "657634", "abstract" : "The immediate effects of surgical dissection on regional bone blood flow were studied using the hydrogen washout technique and the results were compared in mature and immature rabbits. Epiphyseal circulation in young animals was eliminated by stripping the epiphyseal periosteum, and even in mature rabbits epiphyseal blood flow was markedly reduced by periosteal stripping. This suggests that after skeletal maturity blood supply crossing from the metaphysis into the epiphysis is limited. The blood flow rate was not altered by wide reaming of the epiphyseal center in either young or old animals. The rates of bone blood flow in the metaphysis and diaphysis were not altered by separate periosteal stripping or medullary reaming in either age group. Combined reaming and stripping eliminated blood flow in the diaphyseal cortical bone, but in the metaphysis fairly rapid blood flow remained even after reaming and periosteal stripping were done. These findings suggest that arterial supply and venous drainage traverse both endosteal and periosteal surfaces, and either system is capable of sustaining adequate bone tissue circulation.", "author" : [ { "dropping-particle" : "", "family" : "Whiteside", "given" : "L A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ogata", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lesker", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reynolds", "given" : "F C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-1", "issue" : "131", "issued" : { "date-parts" : [ [ "0", "1" ] ] }, "page" : "266-72", "title" : "The acute effects of periosteal stripping and medullary reaming on regional bone blood flow.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[59]", "plainTextFormattedCitation" : "[59]", "previouslyFormattedCitation" : "[59]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[59].Exchange nailing associated with bone loss/debridement has some limitations. There may not be adequate bone proximally or distally to allow stable fixation with a nailADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2106/jbjs.f.00742", "ISSN" : "0021-9355", "author" : [ { "dropping-particle" : "", "family" : "Brinker", "given" : "M R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "D P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-American Volume", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 33\nBrinker, Mark R. O'Connor, Daniel P.\n45", "page" : "177-188", "title" : "Exchange nailing of ununited fractures", "type" : "article-journal", "volume" : "89A" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26]", "plainTextFormattedCitation" : "[26]", "previouslyFormattedCitation" : "[26]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26]. In the humerus, the medullary canal becomes narrow and flat at the lower end, which may limit the possibility of achieving satisfactory stability with a nail in the presence of bone lossADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "1624516", "abstract" : "We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.", "author" : [ { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bell", "given" : "K M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Court-Brown", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "M M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "1992", "7" ] ] }, "page" : "558-62", "title" : "Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/0301-620X.87B2.15874", "ISSN" : "0301-620X", "author" : [ { "dropping-particle" : "", "family" : "Keating", "given" : "J. F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery - British Volume", "id" : "ITEM-2", "issue" : "2", "issued" : { "date-parts" : [ [ "2005", "2", "1" ] ] }, "page" : "142-150", "title" : "The management of fractures with bone loss", "type" : "article-journal", "volume" : "87-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[13,62]", "plainTextFormattedCitation" : "[13,62]", "previouslyFormattedCitation" : "[13,62]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[13,62].Court-Brown et alADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "abstract" : "There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series.", "author" : [ { "dropping-particle" : "", "family" : "Court-Brown", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "J F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McQueen", "given" : "M M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-British Volume", "genre" : "JOUR", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "1992" ] ] }, "note" : "From Duplicate 2 ( \n\n\n\n\n\n\n\n\nInfection after intramedullary nailing of the tibia. Incidence and protocol for management.\n\n\n\n\n\n\n\n\n- Courtbrown, C M; Keating, J F; McQueen, M M )\n\n\n\n\n\n\n\nTimes Cited: 80\n81", "page" : "770-774", "title" : "Infection after intramedullary nailing of the tibia. Incidence and protocol for management.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[89]", "plainTextFormattedCitation" : "[89]", "previouslyFormattedCitation" : "[89]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[89] described a protocol for the treatment of infected tibia diaphyseal nonunions. This protocol has been reported to achieve eradication of the infection with bone union in 12/13 cases (92.3%). More recent series have reported union and eradication of infection in 27/31 (87.1%) tibiae but 19/31 required more than one exchange nail procedure to achieve unionADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Tsang", "given" : "STJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mills", "given" : "Leanora Anne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baren", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frantzias", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "J F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A Hamish R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone and joint journal", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2016" ] ] }, "page" : "534-541", "title" : "Exchange nailing for nonunion of diaphyseal fractures of the tibia. Our results and an analysis of the risk factors for failure", "type" : "article-journal", "volume" : "98 B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[24]", "plainTextFormattedCitation" : "[24]", "previouslyFormattedCitation" : "[24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[24]. Similar results have been found with this protocol in the femurADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2015.09.027", "ISSN" : "1879-0267", "PMID" : "26489394", "abstract" : "The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.", "author" : [ { "dropping-particle" : "", "family" : "Tsang", "given" : "STJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mills", "given" : "LA", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baren", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frantzias", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "JF", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "AHRW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2015", "12" ] ] }, "page" : "2404-9", "title" : "Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure.", "type" : "article-journal", "volume" : "46" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "abstract" : "OBJECTIVES: To investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunion after intramedullary (IM) nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing. DESIGN: Retrospective consecutive clinical series. SETTING: Level I trauma center and tertiary university hospital. PATIENTS: Twenty-three patients were identified whose radiographs failed to show progression of healing for four months after treatment with a reamed IM femoral nail. Nineteen patients had undergone primary IM nailing of an acute femoral shaft fracture, one patient had been converted to an IM nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing. INTERVENTION: All patients were treated by exchange reamed femoral nailing. The diameter of the new nail was one to three millimeters larger than that of the previous nail (the majority were two millimeters larger). The intramedullary canal was overreamed by one millimeter more than the diameter of the nail. Most of the nails were statically locked, and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed or by applying compression with a femoral distractor. MAIN OUTCOME MEASUREMENTS: Radiographic evaluation of union was determined by the presence of healing on at least three of four cortices. Factors reviewed included the patient's age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures. RESULTS: Tobacco use was found to have a detrimental impact on the success of exchange reamed nailing. All eight of the nonsmokers healed after exchange reamed nailing, whereas only ten of the fifteen smokers (66.7 percent) healed after exchange reamed nailing. Overall, exchange reamed femoral nailing was successful in eighteen cases (78.3 percent). Three patients achieved union with additional procedures. Intramedullary cultures were positive in five cases; all of these achieved successful union. CONCLUSIONS: Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed IM nailing has low morbidity, may obviate the need for addition\u2026", "author" : [ { "dropping-particle" : "", "family" : "Hak", "given" : "D J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lee", "given" : "S S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goulet", "given" : "J A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "178-182", "title" : "Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "0009-921X", "PMID" : "3769283", "abstract" : "Between 1970 and 1977, 64 patients with infected pseudarthrosis of the femur and tibia were treated with an interlocking nail. The type of primary treatment prior to the development of the infected pseudarthrosis was plate fixation in 21 femurs and seven tibias and conventional intramedullary nails in 16 femurs and 20 tibias. Fracture union was obtained in 34 of the 38 femoral infected pseudarthrosis (89.5%) and 19 of 27 tibial infected nonunions (62.5%) following interlocking nailing. Seven of the eight failures (87.5%) in the tibial group were the result of reoperation with interlocking nails following infected plate fixation. Following removal of the interlocking nail and treatment of residual infection, osteomyelitis was considered quiescent in 59 patients (35 femurs and 24 tibias) and active in five patients (two femurs and three tibias). Today, external fixation in combination with gentamicin-PMMA chains for local antibiotic treatment is used in the majority of such cases, because fracture instability and the chronic osteomyelitis can be treated simultaneously.", "author" : [ { "dropping-particle" : "", "family" : "Klemm", "given" : "K W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-3", "issue" : "212", "issued" : { "date-parts" : [ [ "1986", "11" ] ] }, "note" : "Between 1970 and 1977, 64 patients with infected pseudarthrosis of the femur and tibia were treated with an interlocking nail. The type of primary treatment prior to the development of the infected pseudarthrosis was plate fixation in 21 femurs and seven tibias and conventional intramedullary nails in 16 femurs and 20 tibias. Fracture union was obtained in 34 of the 38 femoral infected pseudarthrosis (89.5%) and 19 of 27 tibial infected nonunions (62.5%) following interlocking nailing. Seven of the eight failures (87.5%) in the tibial group were the result of reoperation with interlocking nails following infected plate fixation. Following removal of the interlocking nail and treatment of residual infection, osteomyelitis was considered quiescent in 59 patients (35 femurs and 24 tibias) and active in five patients (two femurs and three tibias). Today, external fixation in combination with gentamicin-PMMA chains for local antibiotic treatment is used in the majority of such cases, because fracture instability and the chronic osteomyelitis can be treated simultaneously.", "page" : "174-81", "title" : "Treatment of infected pseudarthrosis of the femur and tibia with an interlocking nail.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[23,91,92]", "plainTextFormattedCitation" : "[23,91,92]", "previouslyFormattedCitation" : "[23,91,92]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[23,91,92]. Tsang et al found that 9/11 (82%) infected femoral nonunions went on to unite but with 6/11 (55%) requiring more than one exchange nail procedure in order to achieve union. Some smaller series have found that the presence of infection was not associated with failure if organism-specific antibiotics were started from the time of exchange nailingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "abstract" : "OBJECTIVES: To investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunion after intramedullary (IM) nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing. DESIGN: Retrospective consecutive clinical series. SETTING: Level I trauma center and tertiary university hospital. PATIENTS: Twenty-three patients were identified whose radiographs failed to show progression of healing for four months after treatment with a reamed IM femoral nail. Nineteen patients had undergone primary IM nailing of an acute femoral shaft fracture, one patient had been converted to an IM nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing. INTERVENTION: All patients were treated by exchange reamed femoral nailing. The diameter of the new nail was one to three millimeters larger than that of the previous nail (the majority were two millimeters larger). The intramedullary canal was overreamed by one millimeter more than the diameter of the nail. Most of the nails were statically locked, and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed or by applying compression with a femoral distractor. MAIN OUTCOME MEASUREMENTS: Radiographic evaluation of union was determined by the presence of healing on at least three of four cortices. Factors reviewed included the patient's age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures. RESULTS: Tobacco use was found to have a detrimental impact on the success of exchange reamed nailing. All eight of the nonsmokers healed after exchange reamed nailing, whereas only ten of the fifteen smokers (66.7 percent) healed after exchange reamed nailing. Overall, exchange reamed femoral nailing was successful in eighteen cases (78.3 percent). Three patients achieved union with additional procedures. Intramedullary cultures were positive in five cases; all of these achieved successful union. CONCLUSIONS: Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed IM nailing has low morbidity, may obviate the need for addition\u2026", "author" : [ { "dropping-particle" : "", "family" : "Hak", "given" : "D J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lee", "given" : "S S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goulet", "given" : "J A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "178-182", "title" : "Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0009-921X", "PMID" : "3769283", "abstract" : "Between 1970 and 1977, 64 patients with infected pseudarthrosis of the femur and tibia were treated with an interlocking nail. The type of primary treatment prior to the development of the infected pseudarthrosis was plate fixation in 21 femurs and seven tibias and conventional intramedullary nails in 16 femurs and 20 tibias. Fracture union was obtained in 34 of the 38 femoral infected pseudarthrosis (89.5%) and 19 of 27 tibial infected nonunions (62.5%) following interlocking nailing. Seven of the eight failures (87.5%) in the tibial group were the result of reoperation with interlocking nails following infected plate fixation. Following removal of the interlocking nail and treatment of residual infection, osteomyelitis was considered quiescent in 59 patients (35 femurs and 24 tibias) and active in five patients (two femurs and three tibias). Today, external fixation in combination with gentamicin-PMMA chains for local antibiotic treatment is used in the majority of such cases, because fracture instability and the chronic osteomyelitis can be treated simultaneously.", "author" : [ { "dropping-particle" : "", "family" : "Klemm", "given" : "K W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-2", "issue" : "212", "issued" : { "date-parts" : [ [ "1986", "11" ] ] }, "note" : "Between 1970 and 1977, 64 patients with infected pseudarthrosis of the femur and tibia were treated with an interlocking nail. The type of primary treatment prior to the development of the infected pseudarthrosis was plate fixation in 21 femurs and seven tibias and conventional intramedullary nails in 16 femurs and 20 tibias. Fracture union was obtained in 34 of the 38 femoral infected pseudarthrosis (89.5%) and 19 of 27 tibial infected nonunions (62.5%) following interlocking nailing. Seven of the eight failures (87.5%) in the tibial group were the result of reoperation with interlocking nails following infected plate fixation. Following removal of the interlocking nail and treatment of residual infection, osteomyelitis was considered quiescent in 59 patients (35 femurs and 24 tibias) and active in five patients (two femurs and three tibias). Today, external fixation in combination with gentamicin-PMMA chains for local antibiotic treatment is used in the majority of such cases, because fracture instability and the chronic osteomyelitis can be treated simultaneously.", "page" : "174-81", "title" : "Treatment of infected pseudarthrosis of the femur and tibia with an interlocking nail.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[91,92]", "plainTextFormattedCitation" : "[91,92]", "previouslyFormattedCitation" : "[91,92]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[91,92]. (iii) Custom made antibiotic-coated cement rods and cement-coated nails. Antibiotic-coated cement rods were first used in the 1990s with recent studies reporting promising results in the treatment of chronic osteomyelitis and infected nonunionsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.96B10.33799", "ISSN" : "2049-4408", "PMID" : "25274920", "abstract" : "The treatment of infected nonunions is difficult. Antibiotic cement-coated (ACC) rods provide stability as well as delivering antibiotics. We conducted a review of 110 infected nonunions treated with ACC rods. Patients were divided into two groups: group A (67 patients) with an infected arthrodesis, and group B (43 patients) with an infected nonunion in a long bone. In group A, infected arthrodesis, the success rate after the first procedure was 38/67 (57%), 29/67 (43%) required further surgery for either control of infection or non-union. At last follow-up, five patients required amputation, representing a limb salvage rate of 62/67 (93%) overall. In all, 29/67 (43%) presented with a bone defect with a mean size of 6.78 cm (2 to 25). Of those with a bone defect, 13/29 (45%) required further surgery and had a mean size of defect of 7.2 cm (3.5 to 25). The cultures were negative in 17/67 (26%) and the most common organism cultured was methicillin-resistant staphylococcus aureus (MRSA) (23/67, (35%)). In group B, long bones nonunion, the success rate after the first procedure was 26/43 (60%), 17/43 (40%) required further surgery for either control of infection or nonunion. The limb salvage rate at last follow-up was 43/43 (100%). A total of 22/43 (51%) had bone defect with a mean size of 4.7 cm (1.5 to 11.5). Of those patients with a bone defect, 93% required further surgery with a mean size of defect of 5.4 cm (3 to 8.5). The cultures were negative in 10/43 (24%) and the most common organism cultured was MRSA, 15/43 (35%). ACC rods are an effective form of treatment for an infected nonunion, with an acceptable rate of complications.", "author" : [ { "dropping-particle" : "", "family" : "Conway", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mansour", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kotze", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Specht", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shabtai", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2014", "10" ] ] }, "page" : "1349-54", "title" : "Antibiotic cement-coated rods: an effective treatment for infected long bones and prosthetic joint nonunions.", "type" : "article-journal", "volume" : "96-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[93]", "plainTextFormattedCitation" : "[93]", "previouslyFormattedCitation" : "[93]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[93]. Numerous techniques for the intraoperative fabrication of antibiotic rods have been described including the use of a mouldADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BOT.0b013e31803ea9e6", "ISSN" : "0890-5339", "author" : [ { "dropping-particle" : "", "family" : "Thonse", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Conway", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 17\nThonse, Raghuram Conway, Janet\n17", "page" : "258-268", "title" : "Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.2106/jbjs.h.00753", "ISSN" : "0021-9355", "author" : [ { "dropping-particle" : "", "family" : "Thonse", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Conway", "given" : "J D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-American Volume", "genre" : "JOUR", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2008" ] ] }, "note" : "Times Cited: 10\nThonse, Raghuram Conway, Janet D.\n10\n4", "page" : "163-174", "title" : "Antibiotic Cement-Coated Nails for the Treatment of Infected Nonunions and Segmental Bone Defects", "type" : "article-journal", "volume" : "90A" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[94,95]", "plainTextFormattedCitation" : "[94,95]", "previouslyFormattedCitation" : "[94,95]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[94,95], manual rolling of the cementADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.4103/0019-5413.55468", "ISSN" : "1998-3727", "PMID" : "19838392", "abstract" : "BACKGROUND: In cases with infected non-union, the primary step is eradication of the infection before attempting to achieve union. Release of antibiotics from the bone cement at a high concentration and its penetration to the surrounding tissues, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. The aim of this study is to summarize our experience with the use of antibiotic cement-impregnated intramedullary nail (ACIIN) for control of infection in cases of infected non-union with bone defect.\n\nMATERIALS AND METHODS: We prospectively studied 25 cases of infected non-union (23 femora and two tibiae). There were 24 males and one female, with the mean age being 33 years (range, 21-58 years). All patients had high-velocity road traffic accidents except one patient who had farmland injury. There were seven closed fractures, one grade I compound, two grade II compound fractures, five grade IIIA compound fractures, and 10 grade IIIB compound fractures. ACIIN was used in all cases after adequate debridement. Patients were classified according to the amount of bone defect present after debridement: group 1 with bone defect <4 cm (n=13), group 2 with bone defect >/=4-<6 cm (n=7), and group 3 with bone defect >/=6 cm (n=5). Infection control was judged on the basis of discharge through the wound and laboratory parameters. All patients were followed-up, with an average follow-up time of 29 months (range, 18-40 months). The mean duration of retention of the intramedullary rod was 8 weeks (range, 6-12 weeks).\n\nRESULTS: In group 1, all cases achieved infection control, with three patients achieving bone union without any need of secondary procedure. In group 2, all cases achieved infection control but the time taken was significantly longer than for group 1 (P value 0.0002). All the cases required a secondary procedure in the form of either interlocking intramedullary nailing with iliac crest bone graft or Ilizarov ring fixator application to achieve union. None of the cases in group 3 achieved infection control.\n\nCONCLUSION: ACIINs are useful for infection control in cases of infected non-union with bone defect <6 cm. In cases with defect >6 cm, other alternatives should be used.", "author" : [ { "dropping-particle" : "", "family" : "Shyam", "given" : "Ashok K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sancheti", "given" : "Parag K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Salim K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rocha", "given" : "Steve", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pradhan", "given" : "Chetan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patil", "given" : "Atul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Indian journal of orthopaedics", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2009", "10" ] ] }, "page" : "396-402", "title" : "Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bones.", "type" : "article-journal", "volume" : "43" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[96]", "plainTextFormattedCitation" : "[96]", "previouslyFormattedCitation" : "[96]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[96], or the use of a chest drain tubing as a mouldADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2013.05.001", "ISSN" : "1879-0267", "PMID" : "23747122", "abstract" : "INTRODUCTION: This is a single, level 1 trauma centre, prospective consecutive patient series with intramedullary infection in the presence of unstable tibial fracture treated using the Kirschner wire-reinforced, antibiotic cement nail.\n\nPATIENTS AND METHODS: A total of 10 consecutive patients (eight males and two females) with a mean age of 42 years (range, 20-59) suffering from infection after intramedullary nailing for tibial fracture, admitted during a period of 4 years, were included. An antibiotic cement-coated nail, handmade at the time of surgery, was implanted in all patients. This was followed by a standardised 6-week treatment protocol, extraction of the nail and definitive fixation.\n\nRESULTS: At 6 years of follow-up, infection eradication and bony union were possible in all of the patients. No further infection treatment was necessary; however, all of our patients underwent additional procedures (mean: four additional procedures per patient) for cosmetic or other non-infectious reasons (bone grafting, muscle flaps, etc.).\n\nCONCLUSIONS: The antibiotic cement-coated nail seems to be an effective treatment for intramedullary infections of the fractured tibia.", "author" : [ { "dropping-particle" : "", "family" : "Wasko", "given" : "Marcin Krzysztof", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borens", "given" : "Olivier", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2013", "8" ] ] }, "page" : "1057-60", "title" : "Antibiotic cement nail for the treatment of posttraumatic intramedullary infections of the tibia: midterm results in 10 cases.", "type" : "article-journal", "volume" : "44" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1097/00005131-200211000-00007", "ISSN" : "0890-5339", "abstract" : "The treatment of intramedullary infections after nailing usually includes removal of the rod, debridement of the canal, and, in many cases, insertion of antibiotic-impregnated cement beads. These beads offer no mechanical support and are difficult to remove if left in place for more than 2 weeks. We present an alternative for filling the medullary canal's noncollapsible dead space with an antibiotic-impregnated cement rod. This rod can be custom-made at the time of surgery, using different diameter chest tubes as molds and embedding a 3-mm beaded guidewire within the cement. The smooth molded surface of this nail makes extraction of the cement rod relatively easy. The cement rod also provides some limited temporary support to the fracture or nonunion site while the infection is being treated. After 6 weeks, the rod can be removed and replaced with a definitive metal intramedullary nail, with or without bone grafting to treat the previously infected fracture or nonunion site. We retrospectively reviewed nine cases of intramedullary infection treated with antibiotic-impregnated molded cement rods. These included six femora, two tibiae, and one humerus. The cause of infection was lengthening or transport over nail in six cases, fixator-augmented nailing of osteotomies in two, and fracture fixation in one. The follow-up period after surgery ranged from 38 to 48 months. No recurrent infection occurred during this follow-up period, and no patient required antibiotics after the rod was removed. In all cases, the canal cultures were negative after rod removal. The cement rod was removed between 29 and 753 days after implantation. Fracture of the rod occurred in one case in which the rod was left in place for more than I year. We conclude that this method is a relatively simple and inexpensive alternative for the treatment of intramedullary infections.", "author" : [ { "dropping-particle" : "", "family" : "Paley", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Herzenberg", "given" : "J E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2002" ] ] }, "note" : "Times Cited: 25\n26", "page" : "723-729", "title" : "Intramedullary infections treated with antibiotic cement rods: Preliminary results in nine cases", "type" : "article-journal", "volume" : "16" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1097/BOT.0b013e31819f27aa", "ISSN" : "1531-2291", "PMID" : "19390373", "abstract" : "This article focuses on the surgical indications and techniques of antibiotic nailing of the femur. Spanning external fixation is an essential component of damage control orthopaedics. Fractures of the femur with significant soft tissue injury also often require prolonged external fixation, which increases the risk of infection. Antibiotic nails can sterilize the medullary canal contaminated by external fixator pins and prophylax against nosocomial infection, while the pin tracts heal to prepare the canal environment for a future staged metal nailing. Antibiotic nails may also be used as a bridge to definitive metallic intramedullary nailing after spanning external fixation in patients with multiple injuries or mangled limbs.", "author" : [ { "dropping-particle" : "", "family" : "Bhadra", "given" : "Arup K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roberts", "given" : "Craig S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of orthopaedic trauma", "id" : "ITEM-3", "issue" : "5 Suppl", "issued" : { "date-parts" : [ [ "0", "1" ] ] }, "page" : "S26-30", "title" : "Indications for antibiotic cement nails.", "type" : "article-journal", "volume" : "23" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "ISSN" : "0147-7447", "abstract" : "This article introduces the antibiotic impregnated cement nail for the treatment for the tibial shaft fracture infection and outlines the technique regarding its placement.", "author" : [ { "dropping-particle" : "", "family" : "Madanagopal", "given" : "S G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seligson", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roberts", "given" : "C S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Orthopedics", "genre" : "JOUR", "id" : "ITEM-4", "issued" : { "date-parts" : [ [ "2004" ] ] }, "note" : "Times Cited: 15\n17", "page" : "709-712", "title" : "The antibiotic cement nail for infection after tibial nailing", "type" : "article-journal", "volume" : "27" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "DOI" : "10.1007/s00402-007-0315-x", "ISSN" : "0936-8051", "PMID" : "17387498", "abstract" : "The treatment of intramedullary infections after nailing usually includes removal of the nail, debridement, and, in some cases, insertion of antibiotic-impregnated cement beads. We use this self-made antibiotic cement rod to treat intramedullary infections. Compared with the beads, it provides some limited mechanical support and can be preserved in the canal for a long time. We reviewed 19 infected patients who underwent removal of the nails, excision of sinus tracks, debridement of the canal and insertion of the rods. No recurrent infection occurred in 18 cases and 11 cases achieved bone healing, 6 cases achieved partial union. One patient had nonunion and one patient underwent amputation because of severe primary trauma and long-term infection. The rod was removed between 35 and 123 days after implantation. We conclude that the antibiotic cement rods could be a relatively effective, simple and inexpensive method of treating intramedullary infections after nailing.", "author" : [ { "dropping-particle" : "", "family" : "Qiang", "given" : "Zheng", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jun", "given" : "Pan Zhi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jie", "given" : "Xu Jian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hang", "given" : "Li", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bing", "given" : "Li Jian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cai", "given" : "Li Fang", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of orthopaedic and trauma surgery", "id" : "ITEM-5", "issue" : "10", "issued" : { "date-parts" : [ [ "2007", "12" ] ] }, "page" : "945-51", "title" : "Use of antibiotic cement rod to treat intramedullary infection after nailing: preliminary study in 19 patients.", "type" : "article-journal", "volume" : "127" }, "uris" : [ "" ] }, { "id" : "ITEM-6", "itemData" : { "ISSN" : "1934-3418", "PMID" : "20305835", "abstract" : "Acute or chronic infection in the presence of nonunited fracture or chronic nonunion often necessitates staged surgical treatment. Treatment typically involves removal of hardware, d\u00e9bridement of infected tissue, use of local antibiotic delivery, and a long-term course of intravenous antibiotics. Several methods of local antibiotic delivery using antibiotic-impregnated polymethylmethacrylate (PMMA) have been commonly used, including commercial or hand-fashioned PMMA beads, antibiotic spacers, and antibiotic PMMA-coated guide rods. While these methods address the problem of infection, they do little to address fracture stability. In this report we describe a simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail to treat an infected tibia fracture. This technique capitalizes on local delivery of antibiotics through use of antibiotic cement with the added benefit of improving fracture stability and fixation with an interlocking nail to achieve bony union.", "author" : [ { "dropping-particle" : "", "family" : "Riel", "given" : "Ryan U", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gladden", "given" : "Paul B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "American journal of orthopedics (Belle Mead, N.J.)", "id" : "ITEM-6", "issue" : "1", "issued" : { "date-parts" : [ [ "2010", "1" ] ] }, "page" : "18-21", "title" : "A simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] }, { "id" : "ITEM-7", "itemData" : { "DOI" : "10.1016/j.injury.2014.03.006", "ISSN" : "1879-0267", "PMID" : "24709474", "abstract" : "INTRODUCTION: The management of intramedullary long bone infections remains a challenge. Placement of antibiotic cement nails is a useful adjuvant to the antibiotic treatment of osteomyelitis. However, fabrication of antibiotic cement nails can be arduous. The purpose of this article is to introduce an easy and reproducible technique for the fabrication of antibiotics cement nails.\n\nMATERIALS AND METHODS: We compared the time required to peel the chest tube off the 6 antibiotic cement nail using 2 different cement-cooling techniques and the addition of mineral oil in the chest tube. Additionally, we evaluated the optimal time to cut the chest tube (before and after cement hardening), consistency of nail's diameter, and the roughness of its surface. Cooling and peeling times were measured and failure was defined as a working time (from cement mixing to have a usable antibiotic cement nail) that exceeded 1 h.\n\nRESULTS: When the antibiotic cement nail was left to cool by convection (i.e. air-cooling), we failed to peel the plastic off the cement nail. When the chest tube was cut after conductive cooling (i.e. cold water-cooled), the cooling time was 10 min and the peeling time was 30 min without the use of mineral oil; the addition of mineral oil reduced peeling time to 7.5 min. Following peeling, residual adherent plastic pieces were found along the entire surface of the nail when no mineral oil was used. This was rarely seen when mineral oil was utilized to coat the inner layer of the chest tube.\n\nCONCLUSION: Conductively cooling of the cement nail (in cold water) and pre-lubricating the chest tube with mineral oil are 2 tricks that render fabrication of antibiotic nail more efficient, reliable, and practical.", "author" : [ { "dropping-particle" : "", "family" : "Kim", "given" : "Ji Wan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cuellar", "given" : "Derly O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hao", "given" : "Jiandong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seligson", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mauffrey", "given" : "Cyril", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-7", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8" ] ] }, "page" : "1179-84", "title" : "Custom-made antibiotic cement nails: a comparative study of different fabrication techniques.", "type" : "article-journal", "volume" : "45" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[97\u2013103]", "plainTextFormattedCitation" : "[97\u2013103]", "previouslyFormattedCitation" : "[97\u2013103]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[97–103]. They can be inserted with minimal soft tissue and periosteal disruption. When used in combination with systemic antibiotics and as part of a staged treatment strategy, eradication and union rates in excess of 95% and 90%, respectively have been reported. However due to PMMA being non-biodegradable it can act as a nidus for glycocalyx-producing bacteria despite the presence of local antibiotics. The resulting biofilm can lead to persistence of the infection or development of secondary infections.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.93B2.24933", "ISSN" : "0301-620X", "PMID" : "21282751", "abstract" : "Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity. This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.", "author" : [ { "dropping-particle" : "", "family" : "El-Husseiny", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacFarlane", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haddad", "given" : "F S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011", "2" ] ] }, "page" : "151-7", "title" : "Biodegradable antibiotic delivery systems.", "type" : "article-journal", "volume" : "93" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[28]", "plainTextFormattedCitation" : "[28]", "previouslyFormattedCitation" : "[28]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[28] Technical difficulties described include removal of the custom-made device from the medullary canalADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1089/sur.2013.166", "ISSN" : "1557-8674", "PMID" : "24871482", "abstract" : "BACKGROUND: The intramedullary insertion of antibiotic-impregnated cement beads is used widely for the treatment of intramedullary infection. This report describes an improved technique for removing chains of antibiotic beads inserted into the intramedullary cavity.\n\nMETHODS: We examined four cases in three patients of the intramedullary insertion of chains of antibiotic-impregnated cement beads for the treatment of osteomyelitis of the diaphysis of the tibia after the fixation of fractures with interlocking nails. During bead removal, the tip of an intramedullary guidewire was bent into a hook shape and was then engaged with the chain of impacted beads. The guidewire was removed from the intramedullary cavity, permitting the extraction of any beads adhering to the wire.\n\nRESULTS: As beads came into contact with the tip of the intramedullary guidewire, they could be extracted easily. No additional incision or bone fenestration was required.\n\nCONCLUSIONS: The use of a hook-shaped intramedullary guidewire simplifies the removal of chains of antibiotic-impregnated cement beads without the need for an invasive procedure. This technique makes the use of chains of cement beads a favorable choice for treating intramedullary infection.", "author" : [ { "dropping-particle" : "", "family" : "Lee", "given" : "Han-Jun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kim", "given" : "Gang-Un", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kang", "given" : "Soo Yong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lee", "given" : "Jae-Sung", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jung", "given" : "Ho-Joong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgical infections", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2014", "12" ] ] }, "page" : "838-42", "title" : "An improved technique for removing intramedullary antibiotic beads in osteomyelitis of the tibial shaft.", "type" : "article-journal", "volume" : "15" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[104]", "plainTextFormattedCitation" : "[104]", "previouslyFormattedCitation" : "[104]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[104], cement-nail debondingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BOT.0b013e31803ea9e6", "ISSN" : "0890-5339", "author" : [ { "dropping-particle" : "", "family" : "Thonse", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Conway", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 17\nThonse, Raghuram Conway, Janet\n17", "page" : "258-268", "title" : "Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[94]", "plainTextFormattedCitation" : "[94]", "previouslyFormattedCitation" : "[94]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[94], fracture of the rod within the medullary canalADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/00005131-200211000-00007", "ISSN" : "0890-5339", "abstract" : "The treatment of intramedullary infections after nailing usually includes removal of the rod, debridement of the canal, and, in many cases, insertion of antibiotic-impregnated cement beads. These beads offer no mechanical support and are difficult to remove if left in place for more than 2 weeks. We present an alternative for filling the medullary canal's noncollapsible dead space with an antibiotic-impregnated cement rod. This rod can be custom-made at the time of surgery, using different diameter chest tubes as molds and embedding a 3-mm beaded guidewire within the cement. The smooth molded surface of this nail makes extraction of the cement rod relatively easy. The cement rod also provides some limited temporary support to the fracture or nonunion site while the infection is being treated. After 6 weeks, the rod can be removed and replaced with a definitive metal intramedullary nail, with or without bone grafting to treat the previously infected fracture or nonunion site. We retrospectively reviewed nine cases of intramedullary infection treated with antibiotic-impregnated molded cement rods. These included six femora, two tibiae, and one humerus. The cause of infection was lengthening or transport over nail in six cases, fixator-augmented nailing of osteotomies in two, and fracture fixation in one. The follow-up period after surgery ranged from 38 to 48 months. No recurrent infection occurred during this follow-up period, and no patient required antibiotics after the rod was removed. In all cases, the canal cultures were negative after rod removal. The cement rod was removed between 29 and 753 days after implantation. Fracture of the rod occurred in one case in which the rod was left in place for more than I year. We conclude that this method is a relatively simple and inexpensive alternative for the treatment of intramedullary infections.", "author" : [ { "dropping-particle" : "", "family" : "Paley", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Herzenberg", "given" : "J E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2002" ] ] }, "note" : "Times Cited: 25\n26", "page" : "723-729", "title" : "Intramedullary infections treated with antibiotic cement rods: Preliminary results in nine cases", "type" : "article-journal", "volume" : "16" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[98]", "plainTextFormattedCitation" : "[98]", "previouslyFormattedCitation" : "[98]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[98] and removing the chest drain tubing from the cured cement nailADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2014.03.006", "ISSN" : "1879-0267", "PMID" : "24709474", "abstract" : "INTRODUCTION: The management of intramedullary long bone infections remains a challenge. Placement of antibiotic cement nails is a useful adjuvant to the antibiotic treatment of osteomyelitis. However, fabrication of antibiotic cement nails can be arduous. The purpose of this article is to introduce an easy and reproducible technique for the fabrication of antibiotics cement nails.\n\nMATERIALS AND METHODS: We compared the time required to peel the chest tube off the 6 antibiotic cement nail using 2 different cement-cooling techniques and the addition of mineral oil in the chest tube. Additionally, we evaluated the optimal time to cut the chest tube (before and after cement hardening), consistency of nail's diameter, and the roughness of its surface. Cooling and peeling times were measured and failure was defined as a working time (from cement mixing to have a usable antibiotic cement nail) that exceeded 1 h.\n\nRESULTS: When the antibiotic cement nail was left to cool by convection (i.e. air-cooling), we failed to peel the plastic off the cement nail. When the chest tube was cut after conductive cooling (i.e. cold water-cooled), the cooling time was 10 min and the peeling time was 30 min without the use of mineral oil; the addition of mineral oil reduced peeling time to 7.5 min. Following peeling, residual adherent plastic pieces were found along the entire surface of the nail when no mineral oil was used. This was rarely seen when mineral oil was utilized to coat the inner layer of the chest tube.\n\nCONCLUSION: Conductively cooling of the cement nail (in cold water) and pre-lubricating the chest tube with mineral oil are 2 tricks that render fabrication of antibiotic nail more efficient, reliable, and practical.", "author" : [ { "dropping-particle" : "", "family" : "Kim", "given" : "Ji Wan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cuellar", "given" : "Derly O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hao", "given" : "Jiandong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seligson", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mauffrey", "given" : "Cyril", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8" ] ] }, "page" : "1179-84", "title" : "Custom-made antibiotic cement nails: a comparative study of different fabrication techniques.", "type" : "article-journal", "volume" : "45" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[103]", "plainTextFormattedCitation" : "[103]", "previouslyFormattedCitation" : "[103]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[103]. (iv) Antibiotic impregnated IM nailsAntibiotic-coated IM nails were initially developed to prevent bacterial colonisation and subsequent biofilm formation during primary fixation of open fractures. Examples include the Expert Tibial Nail (ETN) PROtectTM (DepuySynthes, Johnson/Johnson company, Inc New Jersey, USA). The ETN PROtectTM implant is a titanium alloy (titanium – 6% aluminium – 7% niobium) cannulated nail used for intramedullary fixation of tibia fractures. The fully resorbable antibiotic coating consists of an amorphous poly(D,L-lactide) (PDLLA) matrix containing gentamicin sulphateADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/jbm.1040", "ISSN" : "0021-9304", "author" : [ { "dropping-particle" : "", "family" : "Schmidmaier", "given" : "G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wildemann", "given" : "B.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stemberger", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haas", "given" : "N. P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Raschke", "given" : "M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Biomedical Materials Research", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "449-455", "title" : "Biodegradable poly(D,L-lactide) coating of implants for continuous release of growth factors", "type" : "article-journal", "volume" : "58" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[105]", "plainTextFormattedCitation" : "[105]", "previouslyFormattedCitation" : "[105]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[105]. After implantation, the gentamicin sulphate is delivered to the surrounding tissue in a burst release profile starting at the moment of implantation. Drug kinetic studies have shown that the PROtect implant releases over 40% of its antibiotic within 1 h, 70% within 24 h and 80% within 48 h after implantationADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2015.09.028", "ISSN" : "1879-0267", "PMID" : "26477343", "abstract" : "INTRODUCTION: Despite modern advances in fracture care, deep (implant-related) infection remains a problem in the treatment of tibia fractures. There is some evidence that antibiotic-coated implants are beneficial in the prevention of this sometimes devastating complication. In the following study we describe our results using a gentamicin-coated intramedullary tibia nail (Expert Tibia Nail (ETN) PROtect\u2122) for the surgical treatment of complex open tibia fracture and revision cases.\n\nMATERIALS AND METHODS: We describe the outcome of patients treated between January 2012 and September 2013, using a gentamicin-coated intramedullary tibia nail. Treatment indications included acute, Gustilo grade II-III, open tibia fractures or closed tibia fractures with long-term external fixation prior to intramedullary nailing and complex tibia fracture revision cases with a mean of three prior surgical interventions. Outcome parameters in this study were deep infection and nonunion.\n\nRESULTS: In total, 16 consecutive patients with 16 tibia fractures were treated with a gentamicin-coated intramedullary nail. The overall patient population was subdivided into two groups. The first group consisted of 11 patients (68.8%) with acute fractures who were treated with a gentamicin-coated intramedullary nail. The second group consisted of 5 complex revision cases (31.2%). In our patient population no deep infections could be noted after the treatment with a gentamicin-coated tibia nail. Nonunion was diagnosed in 4 patients (25.0%), 1 of these was a revision case.\n\nCONCLUSIONS: Musculoskeletal complications place a cost burden on total healthcare expenditure. Better understanding of the epidemiology and pathogenesis is essential because this can lead to prevention rather than treatment strategies. The purpose of the study was to evaluate a gentamicin-coated tibia nail in the prevention of deep (implant-related) infection. In our patient population no deep infections occurred after placement of the gentamicin-coated nail. Following this study and literature data, antibiotic-coated implants seem a potential option for prevention of deep infection in trauma patients. In the future this statement needs to be confirmed by large randomised clinical trials.", "author" : [ { "dropping-particle" : "", "family" : "Metsemakers", "given" : "W J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reul", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nijs", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2015", "12" ] ] }, "page" : "2433-7", "title" : "The use of gentamicin-coated nails in complex open tibia fracture and revision cases: A retrospective analysis of a single centre case series and review of the literature.", "type" : "article-journal", "volume" : "46" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[106]", "plainTextFormattedCitation" : "[106]", "previouslyFormattedCitation" : "[106]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[106]. It offers high concentrations of antibiotics locally in addition to the other benefits of exchange nailing. (b) Two Stage Excision of the NonunionTwo-stage revision arthroplasty is the gold standard for the treatment of periprosthetic infections with removal of the prosthesis followed by placement of an antibiotic impregnated spacer and parenteral antibiotic therapy with delayed reimplantation of prostheses once the infection has been eradicatedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "10963167", "abstract" : "We treated 50 consecutive patients with infected total hip arthroplasties according to a standard protocol. Previous surgery to eradicate the infection had been attempted in 13 patients and discharging sinuses were present in 20. Aspiration arthrography was routinely carried out before our interventions. The first stage was a meticulous removal of all foreign and potentially infected material. Samples were taken for culture and a thorough lavage carried out. Antibiotic-loaded beads were placed in the femoral shaft and an antibiotic-loaded cement ball in the acetabulum. At the second stage an uncemented arthroplasty was introduced. Bone allograft was used in 18 patients. The interval between procedures was usually three weeks, but this was extended if the wound was slow to heal or there was extensive bony destruction. Appropriate antibiotics were given for three months. At a mean follow-up of 5.8 years the rate of reinfection was 8% (4 patients). Two of these patients have had another, successful, two-stage revision. At this medium-term review, a satisfactory clinical and radiological outcome was obtained in all except two patients.", "author" : [ { "dropping-particle" : "", "family" : "Haddad", "given" : "F S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Muirhead-Allwood", "given" : "S K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Manktelow", "given" : "A R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bacarese-Hamilton", "given" : "I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2000", "7" ] ] }, "page" : "689-94", "title" : "Two-stage uncemented revision hip arthroplasty for infection.", "type" : "article-journal", "volume" : "82" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/0301-620X.96B10.32875", "ISSN" : "2049-4408", "PMID" : "25274914", "abstract" : "We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases. A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%). The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up. We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.", "author" : [ { "dropping-particle" : "", "family" : "Ibrahim", "given" : "M S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Raja", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Khan", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haddad", "given" : "F S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The bone & joint journal", "id" : "ITEM-2", "issue" : "10", "issued" : { "date-parts" : [ [ "2014", "10" ] ] }, "page" : "1312-8", "title" : "A multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study.", "type" : "article-journal", "volume" : "96-B" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1302/0301-620X.97B9.35295", "ISSN" : "2049-4394", "PMID" : "26330580", "abstract" : "The number of arthroplasties being undertaken is expected to grow year on year, and periprosthetic joint infections will be an increasing socioeconomic burden. The challenge to prevent and eradicate these infections has resulted in the emergence of several new strategies, which are discussed in this review. Cite this article: Bone Joint J 2015;97-B:1162\u20139.", "author" : [ { "dropping-particle" : "", "family" : "George", "given" : "D. A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gant", "given" : "V.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haddad", "given" : "F. S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Bone & Joint Journal", "id" : "ITEM-3", "issue" : "9", "issued" : { "date-parts" : [ [ "2015", "9", "1" ] ] }, "page" : "1162-1169", "title" : "The management of periprosthetic infections in the future: a review of new forms of treatment", "type" : "article-journal", "volume" : "97-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[107\u2013109]", "plainTextFormattedCitation" : "[107\u2013109]", "previouslyFormattedCitation" : "[107\u2013109]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[107–109]. It has been suggested infected nonunions should be treated in a similar manner using a planned series of surgical proceduresADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2106/jbjs.f.00742", "ISSN" : "0021-9355", "author" : [ { "dropping-particle" : "", "family" : "Brinker", "given" : "M R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "D P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-American Volume", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 33\nBrinker, Mark R. O'Connor, Daniel P.\n45", "page" : "177-188", "title" : "Exchange nailing of ununited fractures", "type" : "article-journal", "volume" : "89A" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.injury.2015.08.009", "ISSN" : "1879-0267", "PMID" : "26304000", "abstract" : "Infected non-union is a devastating complication post fracture fixation. While its incidence is small, its management is lengthy, challenging and costly. Complex reconstruction surgery is often required with unpredictable outcomes despite the significant advances that have been made in diagnostics, surgical techniques and antibiotic protocols. In this article we present recent approaches to the surgical treatment of this condition.", "author" : [ { "dropping-particle" : "", "family" : "Kanakaris", "given" : "Nikolaos K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tosounidis", "given" : "Theodoros H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2015", "11" ] ] }, "page" : "S25-32", "title" : "Surgical management of infected non-unions: An update.", "type" : "article-journal", "volume" : "46 Suppl 5" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26,45]", "plainTextFormattedCitation" : "[26,45]", "previouslyFormattedCitation" : "[26,45]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26,45]. The infected intramedullary nail is removed, the canal is reamed as indicated above and dead bone at the non-union excised. The dead space is obliterated with vascular tissue or antibiotic impregnated material and the bone is stabilised (see table 1). External fixation is frequently used in these situations. However, following removal of the infected primary IM nail implantation of an antibiotic-impregnated nail or antibiotic-loaded polymethylmethacrylate cement spacer has been reported to provide temporary internal splinting and elute high concentrations of an antimicrobial drug locally in the medullary canalADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0147-7447", "abstract" : "This article introduces the antibiotic impregnated cement nail for the treatment for the tibial shaft fracture infection and outlines the technique regarding its placement.", "author" : [ { "dropping-particle" : "", "family" : "Madanagopal", "given" : "S G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seligson", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roberts", "given" : "C S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Orthopedics", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2004" ] ] }, "note" : "Times Cited: 15\n17", "page" : "709-712", "title" : "The antibiotic cement nail for infection after tibial nailing", "type" : "article-journal", "volume" : "27" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1097/00005131-200211000-00007", "ISSN" : "0890-5339", "abstract" : "The treatment of intramedullary infections after nailing usually includes removal of the rod, debridement of the canal, and, in many cases, insertion of antibiotic-impregnated cement beads. These beads offer no mechanical support and are difficult to remove if left in place for more than 2 weeks. We present an alternative for filling the medullary canal's noncollapsible dead space with an antibiotic-impregnated cement rod. This rod can be custom-made at the time of surgery, using different diameter chest tubes as molds and embedding a 3-mm beaded guidewire within the cement. The smooth molded surface of this nail makes extraction of the cement rod relatively easy. The cement rod also provides some limited temporary support to the fracture or nonunion site while the infection is being treated. After 6 weeks, the rod can be removed and replaced with a definitive metal intramedullary nail, with or without bone grafting to treat the previously infected fracture or nonunion site. We retrospectively reviewed nine cases of intramedullary infection treated with antibiotic-impregnated molded cement rods. These included six femora, two tibiae, and one humerus. The cause of infection was lengthening or transport over nail in six cases, fixator-augmented nailing of osteotomies in two, and fracture fixation in one. The follow-up period after surgery ranged from 38 to 48 months. No recurrent infection occurred during this follow-up period, and no patient required antibiotics after the rod was removed. In all cases, the canal cultures were negative after rod removal. The cement rod was removed between 29 and 753 days after implantation. Fracture of the rod occurred in one case in which the rod was left in place for more than I year. We conclude that this method is a relatively simple and inexpensive alternative for the treatment of intramedullary infections.", "author" : [ { "dropping-particle" : "", "family" : "Paley", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Herzenberg", "given" : "J E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Trauma", "genre" : "JOUR", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2002" ] ] }, "note" : "Times Cited: 25\n26", "page" : "723-729", "title" : "Intramedullary infections treated with antibiotic cement rods: Preliminary results in nine cases", "type" : "article-journal", "volume" : "16" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1097/00005373-200202000-00025", "ISSN" : "0022-5282", "PMID" : "11835003", "author" : [ { "dropping-particle" : "", "family" : "Ohtsuka", "given" : "Hiroshi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yokoyama", "given" : "Kazuhiko", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Higashi", "given" : "Kei", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tsutsumi", "given" : "Ataru", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fukushima", "given" : "Nobuaki", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Noumi", "given" : "Takashi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Itoman", "given" : "Moritoshi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Trauma-Injury Infection and Critical Care", "genre" : "JOUR", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "2002", "2" ] ] }, "note" : "From Duplicate 2 (Use of antibiotic-impregnated bone cement nail to treat septic nonunion after open tibial fracture - Ohtsuka, H; Yokoyama, K; Higashi, K; Tsutsumi, A; Fukushima, N; Noumi, T; Itoman, M)\n\nTimes Cited: 10\n13", "page" : "364-366", "title" : "Use of antibiotic-impregnated bone cement nail to treat septic nonunion after open tibial fracture", "type" : "article-journal", "volume" : "52" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[98,100,110]", "plainTextFormattedCitation" : "[98,100,110]", "previouslyFormattedCitation" : "[98,100,110]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[98,100,110]. With the final treatment stage being removal of the antibiotic-impregnated nail or spacer and definitive internal fixationADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0147-7447", "abstract" : "This article introduces the antibiotic impregnated cement nail for the treatment for the tibial shaft fracture infection and outlines the technique regarding its placement.", "author" : [ { "dropping-particle" : "", "family" : "Madanagopal", "given" : "S G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seligson", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roberts", "given" : "C S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Orthopedics", "genre" : "JOUR", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2004" ] ] }, "note" : "Times Cited: 15\n17", "page" : "709-712", "title" : "The antibiotic cement nail for infection after tibial nailing", "type" : "article-journal", "volume" : "27" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.2106/jbjs.f.00742", "ISSN" : "0021-9355", "author" : [ { "dropping-particle" : "", "family" : "Brinker", "given" : "M R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Connor", "given" : "D P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery-American Volume", "genre" : "JOUR", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2007" ] ] }, "note" : "Times Cited: 33\nBrinker, Mark R. O'Connor, Daniel P.\n45", "page" : "177-188", "title" : "Exchange nailing of ununited fractures", "type" : "article-journal", "volume" : "89A" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26,100]", "plainTextFormattedCitation" : "[26,100]", "previouslyFormattedCitation" : "[26,100]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26,100].The defect can then be filled using techniques such as bone transport or the Masquelet technique.Bone transport. The use of a frame to carry out bone transport to bridge a defect is an alternative to shortening for longer defects. Circular frames are now more popular for the tibia than uniaxial devices since they confer greater stability and there is more flexibility in the configuration of the frame. There is also more scope for correcting rotational or angular malalignment which may occur during the course of treatmentADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.87B2.15874", "ISSN" : "0301-620X", "author" : [ { "dropping-particle" : "", "family" : "Keating", "given" : "J. F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "C M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Bone and Joint Surgery - British Volume", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2005", "2", "1" ] ] }, "page" : "142-150", "title" : "The management of fractures with bone loss", "type" : "article-journal", "volume" : "87-B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[62]", "plainTextFormattedCitation" : "[62]", "previouslyFormattedCitation" : "[62]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[62]. Union rates reported after Ilizarov treatment are close to 100%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.5812/atr.11300", "ISSN" : "2251-953X", "PMID" : "24396797", "abstract" : "BACKGROUND: The Ilizarov technique has been used in the UK for the last 20 years in the management of infected non-union of long bones. This method uses fine wires inserted percutaneously which are attached and tensioned to provide a strong frame construct. The majority of tibial and femoral non unions can be treated successfully by internal fixation. However, an infected non-union of the tibia can prove a difficult problem. The Ilizarov method can prove useful for treating these complex injuries.\n\nOBJECTIVES: To assess whether a new limb reconstruction centre in the UK has comparable results.\n\nPATIENTS AND METHODS: Twelve patients (10 M: 2 F; Avg age 43.3 years) who had an infected tibial non-union between March 2009 and August 2010 treated with the Ilizarov technique. Intervention method was Ilizarov technique and main outcome measures include functional and radiological outcomes assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analogue Pain scores.\n\nRESULTS: All twelve patients united. None required amputation. Mean time to union was 46 weeks (range 24 - 70/median 50). The average follow up time was 62 weeks (39 - 164/ median 59). According to the ASAMI score bone/radiological results ten were classed as excellent with the remainder being good. Functionally six were graded as excellent, four as good and two as poor. The average AOFAS score was 83/100 (70 - 90) and pain visual analogue scale (VAS) was two.\n\nCONCLUSIONS: Our results in terms of ASAMI scores are comparable with the published literature. Furthermore, our return to work is better than most European studies (63%). All our patients said they would have the procedure again. We attribute this success partly to the multidisciplinary approach. We recommend early referral to a dedicated unit if there is any evidence of a non-union.", "author" : [ { "dropping-particle" : "", "family" : "Shahid", "given" : "Mohammad", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hussain", "given" : "Abid", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bridgeman", "given" : "Phillipa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bose", "given" : "Deepa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of trauma research", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "8" ] ] }, "page" : "71-5", "title" : "Clinical outcomes of the Ilizarov method after an infected tibial non union.", "type" : "article-journal", "volume" : "2" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Venkatesh Gupta", "given" : "S.K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Govindappa", "given" : "C.V.S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rakesh Reddy", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Open access Orthopaedics", "id" : "ITEM-2", "issue" : "4", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "1-6", "title" : "Treatment of infective non-union of diaphyseal fractures with Ilizarov external fixation.", "type" : "article-journal", "volume" : "2" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/j.injury.2009.09.013", "ISSN" : "0020-1383", "author" : [ { "dropping-particle" : "", "family" : "Megas", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saridis", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kouzelis", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kallivokas", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mylonas", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tyllianakis", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury-International Journal of the Care of the Injured", "genre" : "JOUR", "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "note" : "Times Cited: 5\nMegas, Panagiotis Saridis, Alkis Kouzelis, Antonis Kallivokas, Alkiviadis Mylonas, Spyros Tyllianakis, Minos\n9\nSi", "page" : "294-299", "title" : "The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method", "type" : "article-journal", "volume" : "41" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[68\u201370]", "plainTextFormattedCitation" : "[68\u201370]", "previouslyFormattedCitation" : "[68\u201370]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[68–70]. However, Ilizarov treatment requires a second procedure to remove the frame and several years to regain function after frame?removalADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "14765871", "abstract" : "There are few reports on function after limb salvage surgery using the Ilizarov technique, and none that document the pattern of recovery or predict when maximum function returns. This prospective, longitudinal study documents the baseline functional abilities of 40 consecutive patients with nonunion of a fracture in the lower limb. Patients were studied for at least two and a half years following the completion of surgery. Function was measured by timed tests of functional performance and by the Toronto Extremity Salvage Score self-reported patient questionnaire. Recovery was slowest in the early stages after removal of the frame and greatest between six months and one year. Statistically significant improvement continued up to, but not beyond two years. This observation has important implications for the length of follow-up incorporated into the rehabilitation programmes for patients, predictions of patient status in regard to compensation and for the design of future studies to evaluate functional outcome.", "author" : [ { "dropping-particle" : "", "family" : "Barker", "given" : "K L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lamb", "given" : "S E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2004", "1" ] ] }, "page" : "81-5", "title" : "Functional recovery in patients with nonunion treated with the Ilizarov technique.", "type" : "article-journal", "volume" : "86" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[2]", "plainTextFormattedCitation" : "[2]", "previouslyFormattedCitation" : "[2]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[2]. Modified Masquelet techniqueA further option for defects of 6cm or more following radical debridement is the modified Masquelet techniqueADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2011.03.036", "ISSN" : "00201383", "PMID" : "21543068", "abstract" : "Reconstruction of diaphyseal bone defects still represents a major clinical challenge. Several approaches are used with the common objective to regenerate bone loss and restore function. The methods most commonly used are the vascularised fibula autograft and the Ilizarov bone transfer technique. Recently, Masquelet proposed a procedure combining induced membranes and cancellous autografts. The aim of this article was to briefly describe the technique, to review the current evidence and to discuss the tips and tricks that could help the surgeons to improve outcome. Future directions to increase its effectiveness and expand its application are also being discussed. However, predicting the outcome of reconstruction of bone defects remains difficult; and the patient should always be informed that, although potential complications are mostly predictable, in most of the cases the reconstruction process is long and difficult.", "author" : [ { "dropping-particle" : "V.", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faour", "given" : "Omar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goff", "given" : "Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kanakaris", "given" : "Nikolaos", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dimitriou", "given" : "Rozalia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2011", "6", "1" ] ] }, "language" : "English", "page" : "591-598", "publisher" : "Elsevier", "title" : "Masquelet technique for the treatment of bone defects: Tips-tricks and future directions", "type" : "article-journal", "volume" : "42" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/2046-3758.53.2000487", "ISSN" : "2046-3758", "PMID" : "27033845", "abstract" : "OBJECTIVES: Induced membrane technique is a relatively new technique in the reconstruction of large bone defects. It involves the implantation of polymethylmethacrylate (PMMA) cement in the bone defects to induce the formation of membranes after radical debridement and reconstruction of bone defects using an autologous cancellous bone graft in a span of four to eight weeks. The purpose of this study was to explore the clinical outcomes of the induced membrane technique for the treatment of post-traumatic osteomyelitis in 32 patients.\n\nMETHODS: A total of 32 cases of post-traumatic osteomyelitis were admitted to our department between August 2011 and October 2012. This retrospective study included 22 men and ten women, with a mean age of 40 years (19 to 70). Within this group there were 20 tibias and 12 femurs with a mean defect of 5 cm (1.5 to 12.5). Antibiotic-loaded PMMA cement was inserted into the defects after radical debridement. After approximately eight weeks, the defects were implanted with bone graft.\n\nRESULTS: The patients were followed for 27.5 months (24 to 32). Radiographic bone union occurred at six months for 26 cases (81%) and clinical healing occurred in 29 cases (90%) at ten months. A total of six cases had a second debridement before bone grafting because of recurrence of infection and one patient required a third debridement. No cases of osteomyelitis had recurred at the time of the last follow-up visit.\n\nCONCLUSION: The induced membrane technique for the treatment of post-traumatic osteomyelitis is a simple, reliable method, with good early results. However, there are many challenges in determining the scope of the debridement, type of limb fixation and source of bone graft to be used.Cite this article: Dr Z. Xie. Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res 2016;5:101-105. DOI: 10.1302/2046-3758.53.2000487.", "author" : [ { "dropping-particle" : "", "family" : "Wang", "given" : "X", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Luo", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Huang", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Xie", "given" : "Z", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone & joint research", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2016", "3" ] ] }, "page" : "101-5", "title" : "Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis.", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[111,112]", "plainTextFormattedCitation" : "[111,112]", "previouslyFormattedCitation" : "[111,112]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[111,112]. During the first stage of the Masquelet technique a polymethylmethacrylate (PMMA) cement spacer is implanted at the site of the bone defect and the limb is stabilised with an external fixator. The cement spacer had two roles in the original description. The first one was mechanical as it prevented fibrous tissue invasion of the recipient site. The second role was biological as the PMMA induced the surrounding membrane that was able to revascularise the bone graft and prevent its resorption. A third role was as a medium for the local delivery of high concentrations of antibiotics at the infected nonunion siteADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.injury.2011.03.036", "ISSN" : "00201383", "PMID" : "21543068", "abstract" : "Reconstruction of diaphyseal bone defects still represents a major clinical challenge. Several approaches are used with the common objective to regenerate bone loss and restore function. The methods most commonly used are the vascularised fibula autograft and the Ilizarov bone transfer technique. Recently, Masquelet proposed a procedure combining induced membranes and cancellous autografts. The aim of this article was to briefly describe the technique, to review the current evidence and to discuss the tips and tricks that could help the surgeons to improve outcome. Future directions to increase its effectiveness and expand its application are also being discussed. However, predicting the outcome of reconstruction of bone defects remains difficult; and the patient should always be informed that, although potential complications are mostly predictable, in most of the cases the reconstruction process is long and difficult.", "author" : [ { "dropping-particle" : "V.", "family" : "Giannoudis", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faour", "given" : "Omar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goff", "given" : "Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kanakaris", "given" : "Nikolaos", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dimitriou", "given" : "Rozalia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2011", "6", "1" ] ] }, "language" : "English", "page" : "591-598", "publisher" : "Elsevier", "title" : "Masquelet technique for the treatment of bone defects: Tips-tricks and future directions", "type" : "article-journal", "volume" : "42" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[111]", "plainTextFormattedCitation" : "[111]", "previouslyFormattedCitation" : "[111]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[111]. Following placement of a PMMA spacer the soft tissue envelope is repaired (if necessary with vascularised flap). At the second stage, approximately 6–8 weeks later, the cement spacer is carefully removed ensuring that the formed ‘‘induced membrane’’ is minimally disturbed; and the defect is filled with morcellised cancellous autologous bone graft (with additional bone graft substitute if the graft is insufficient, not exceeding a 1:3 ratio). The bone is usually stabilised with a plate, but other means of fixation can be usedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0294-1260", "PMID" : "10929461", "abstract" : "In the reported series of 35 cases bone reconstruction of large diaphyseal defects was performed in two stages. The first stage was the insertion into the defect of a cement spacer which was responsible for the formation of a pseudosynovial membrane. The second stage was the reconstruction of the defect by a huge fresh autologous cancellous bone graft. The membrane induced by the spacer prevents the resorption of the graft and favors its vascularity and its corticalisation. In weight bearing diaphyseal segments the normal walking was possible at 8.5 months on average. The length of the reconstructed defects was 4 to 25 cm.", "author" : [ { "dropping-particle" : "", "family" : "Masquelet", "given" : "A C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fitoussi", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Begue", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Muller", "given" : "G P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annales de chirurgie plastique et esth\u00e9tique", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2000", "6" ] ] }, "page" : "346-53", "title" : "[Reconstruction of the long bones by the induced membrane and spongy autograft].", "type" : "article-journal", "volume" : "45" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[113]", "plainTextFormattedCitation" : "[113]", "previouslyFormattedCitation" : "[113]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[113]. The induced membrane has been shown to be highly vascularised, osteoinductiveADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/S0736-0266(03)00165-7", "ISSN" : "0736-0266", "PMID" : "14656662", "abstract" : "Based on a new concept, a procedure combining induced membranes and cancellous autografts allows the reconstruction of wide diaphyseal defects. In the first stage of this procedure, a cement spacer is inserted into the defect; the spacer is responsible for the formation of a pseudo-synovial membrane. In the second stage, the defect is reconstructed two months later by an autologous cancellous bone graft. The aim of this study was to evaluate the histological and biochemical characteristics of these membranes induced in rabbits. Histological studies carried out two, four, six, and eight weeks following implantation revealed a rich vascularization. Qualitative and quantitative immunochemistry showed production of growth factors (VEGF, TGFbeta1) and osteoinductive factors (BMP-2). Maximum BMP-2 production was obtained four weeks after the implantation, and, at this time, induced membranes favored human bone marrow stromal cell differentiation to the osteoblastic lineage. Should these results be confirmed in humans, bone reconstruction could be carried out earlier than previously thought and in better conditions than expected, the membrane playing the role of an in situ delivery system for growth and osteoinductive factors.", "author" : [ { "dropping-particle" : "", "family" : "Pelissier", "given" : "P. H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Masquelet", "given" : "A. C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bareille", "given" : "R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pelissier", "given" : "S. Mathoulin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Amedee", "given" : "J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Orthopaedic Research", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2004", "1" ] ] }, "page" : "73-79", "title" : "Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[114]", "plainTextFormattedCitation" : "[114]", "previouslyFormattedCitation" : "[114]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[114], and even osteogenicADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/2046-3758.54.2000483", "ISSN" : "2046-3758", "PMID" : "27056768", "abstract" : "OBJECTIVES: The biomembrane (induced membrane) formed around polymethylmethacrylate (PMMA) spacers has value in clinical applications for bone defect reconstruction. Few studies have evaluated its cellular, molecular or stem cell features. Our objective was to characterise induced membrane morphology, molecular features and osteogenic stem cell characteristics.\n\nMETHODS: Following Institutional Review Board approval, biomembrane specimens were obtained from 12 patient surgeries for management of segmental bony defects (mean patient age 40.7 years, standard deviation 14.4). Biomembranes from nine tibias and three femurs were processed for morphologic, molecular or stem cell analyses. Gene expression was determined using the Affymetrix GeneChip Operating Software (GCOS). Molecular analyses compared biomembrane gene expression patterns with a mineralising osteoblast culture, and gene expression in specimens with longer spacer duration (> 12 weeks) with specimens with shorter durations. Statistical analyses used the unpaired student t-test (two tailed; p < 0.05 was considered significant).\n\nRESULTS: Average PMMA spacer in vivo time was 11.9 weeks (six to 18). Trabecular bone was present in 33.3% of the biomembrane specimens; bone presence did not correlate with spacer duration. Biomembrane morphology showed high vascularity and collagen content and positive staining for the key bone forming regulators, bone morphogenetic protein 2 (BMP2) and runt-related transcription factor 2 (RUNX2). Positive differentiation of cultured biomembrane cells for osteogenesis was found in cells from patients with PMMA present for six to 17 weeks. Stem cell differentiation showed greater variability in pluripotency for osteogenic potential (70.0%) compared with chondrogenic or adipogenic potentials (100% and 90.0%, respectively). Significant upregulation of BMP2 and 6, numerous collagens, and bone gla protein was present in biomembrane compared with the cultured cell line. Biomembranes with longer resident PMMA spacer duration (vs those with shorter residence) showed significant upregulation of bone-related, stem cell, and vascular-related genes.\n\nCONCLUSION: The biomembrane technique is gaining favour in the management of complicated bone defects. Novel data on biological mechanisms provide improved understanding of the biomembrane's osteogenic potential and molecular properties.Cite this article: Dr H. E. Gruber. Osteogenic, stem cell and molecular characterisation of the hum\u2026", "author" : [ { "dropping-particle" : "", "family" : "Gruber", "given" : "H E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ode", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hoelscher", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ingram", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bethea", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bosse", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone & joint research", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2016", "4" ] ] }, "page" : "106-15", "title" : "Osteogenic, stem cell and molecular characterisation of the human induced membrane from extremity bone defects.", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[115]", "plainTextFormattedCitation" : "[115]", "previouslyFormattedCitation" : "[115]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[115]. Defects up to 25 cm have been reported to have fully consolidated with the Masquelet technique within 12 monthsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0294-1260", "PMID" : "10929461", "abstract" : "In the reported series of 35 cases bone reconstruction of large diaphyseal defects was performed in two stages. The first stage was the insertion into the defect of a cement spacer which was responsible for the formation of a pseudosynovial membrane. The second stage was the reconstruction of the defect by a huge fresh autologous cancellous bone graft. The membrane induced by the spacer prevents the resorption of the graft and favors its vascularity and its corticalisation. In weight bearing diaphyseal segments the normal walking was possible at 8.5 months on average. The length of the reconstructed defects was 4 to 25 cm.", "author" : [ { "dropping-particle" : "", "family" : "Masquelet", "given" : "A C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fitoussi", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Begue", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Muller", "given" : "G P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annales de chirurgie plastique et esth\u00e9tique", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2000", "6" ] ] }, "page" : "346-53", "title" : "[Reconstruction of the long bones by the induced membrane and spongy autograft].", "type" : "article-journal", "volume" : "45" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[113]", "plainTextFormattedCitation" : "[113]", "previouslyFormattedCitation" : "[113]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[113].(c) One Stage Excision of the Nonunion The infected intramedullary nail is removed, the canal is reamed as indicated above and dead bone at the non-union excised back to two healthy matching bone ends. The limb is then acutely shortened and these bone ends opposed. The limb is then stabilised, most commonly with external fixation but other modalities have been used (table 1). This technique has the advantage of (i) obliterating the dead space between the bone ends and (ii) reducing the size of the soft-tissue defect and potentially avoiding the need for a free flapADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "11476302", "abstract" : "Z-plasty is used to lengthen scars and wounds. We describe the use of a modified technique to shorten wounds in ten consecutive patients undergoing acute shortening of a limb as part of an Ilizarov procedure. The modified technique gave good exposure, easy closure of the wound and fewer problems with healing than standard incisions.", "author" : [ { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Andrews", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giele", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2001", "7" ] ] }, "page" : "668-71", "title" : "Skin closure after acute shortening.", "type" : "article-journal", "volume" : "83" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[63]", "plainTextFormattedCitation" : "[63]", "previouslyFormattedCitation" : "[63]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[63] by using a reverse Z plasty instead. The technique is limited by the amount of acute shortening that can be tolerated. This is dependent on the state of the soft tissues and the site of the defect; indurated chronically infected tissues and arteriosclerotic vessels tolerate shortening less well, whereas young supple tissues may allow 10cms of acute shortening. In certain locations close to joints, the vessels are less mobile, for instance at the ‘trifurcation’ of the popliteal artery and in these cases far less acute shortening is tolerated. As a rule of thumb 5 cms of shortening is possible, but in all cases it is important to monitor the pulses before and after acute shortening.A corticotomy is then created through a healthy area of bone away from the zone of injury. The bone can then be lengthened at the same time as obtaining bony union.This procedure should be considered if the associated soft-tissue defect is shorter than that of the bone. In the upper limb, shortening of 2 to 4 cm may be tolerated without significant functional impairment, obviating the need for subsequent lengthening. The lengthening can be performed at a later time and intramedullary nails have been developed with lengthening capacityADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1302/0301-620X.91B7.21466", "ISSN" : "0301-620X", "PMID" : "19567863", "abstract" : "Femoral lengthening using the Intramedullary Skeletal Kinetic Distractor is a new technique. However, with intramedullary distraction the surgeon has less control over the lengthening process. Therefore, 33 femora lengthened with this device were assessed to evaluate the effect of operative variables under the surgeon's control on the course of lengthening. The desired lengthening was achieved in 32 of 33 limbs. Problems encountered included difficulty in achieving length in eight femora (24%) and uncontrolled lengthening in seven (21%). Uncontrolled lengthening was more likely if the osteotomy was placed with less than 80 mm of the thick portion of the nail in the distal fragment (p = 0.052), and a failure to lengthen was more likely if there was over 125 mm in the distal fragment (p = 0.008). The latter problem was reduced with over-reaming by 2.5 mm to 3 mm. Previous intramedullary nailing also predisposed to uncontrolled lengthening (p = 0.042), and these patients required less reaming. Using the Intramedullary Skeletal Kinetic Distractor, good outcomes were obtained; problems were minimised by optimising the position of the osteotomy and the amount of over-reaming performed.", "author" : [ { "dropping-particle" : "", "family" : "Simpson", "given" : "A H W R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shalaby", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keenan", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "2009", "7" ] ] }, "page" : "955-61", "title" : "Femoral lengthening with the Intramedullary Skeletal Kinetic Distractor.", "type" : "article-journal", "volume" : "91" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1302/0301-620X.91B7.21304", "ISSN" : "0301-620X", "PMID" : "19567864", "abstract" : "We present a retrospective review of a single-surgeon series of 30 consecutive lengthenings in 27 patients with congenital short femur using the Ilizarov technique performed between 1994 and 2005. The mean increase in length was 5.8 cm/18.65% (3.3 to 10.4, 9.7% to 48.8%), with a mean time in the frame of 223 days (75 to 363). By changing from a distal to a proximal osteotomy for lengthening, the mean range of knee movement was significantly increased from 98.1 degrees to 124.2 degrees (p = 0.041) and there was a trend towards a reduced requirement for quadricepsplasty, although this was not statistically significant (p = 0.07). The overall incidence of regenerate deformation or fracture requiring open reduction and internal fixation was similar in the distal and proximal osteotomy groups (56.7% and 53.8%, respectively). However, in the proximal osteotomy group, pre-placement of a Rush nail reduced this rate from 100% without a nail to 0% with a nail (p < 0.001). When comparing a distal osteotomy with a proximal one over a Rush nail for lengthening, there was a significant decrease in fracture rate from 58.8% to 0% (p = 0.043). We recommend that in this group of patients lengthening of the femur with an Ilizarov construct be carried out through a proximal osteotomy over a Rush nail. Lengthening should also be limited to a maximum of 6 cm during one treatment, or 20% of the original length of the femur, in order to reduce the risk of complications.", "author" : [ { "dropping-particle" : "", "family" : "Aston", "given" : "W J S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Calder", "given" : "P R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baker", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hartley", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hill", "given" : "R A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-2", "issue" : "7", "issued" : { "date-parts" : [ [ "2009", "7" ] ] }, "page" : "962-7", "title" : "Lengthening of the congenital short femur using the Ilizarov technique: a single-surgeon series.", "type" : "article-journal", "volume" : "91" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[116,117]", "plainTextFormattedCitation" : "[116,117]", "previouslyFormattedCitation" : "[116,117]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[116,117], which should be considered if the infection has been eradicated. Alternatively, lengthening can be accomplished over a nail after union by creating an osteotomy through healthy bone and applying a uniaxial fixatorADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-921X", "PMID" : "1516319", "abstract" : "The Ilizarov method of segmental bone transport has been shown to be an alternative to more conventional treatments of posttraumatic bony defects. After extensive clinical experience with the unreamed tibial nail in open fractures up to Grade IIIb, a new monorail fixation system for callus distraction and segmental bone transport was devised. This Monorail system is composed of an unreamed intramedullary (IM) nail and a unilateral AO distraction device. The new fixation method and the preliminary clinical experience are reported here. Four patients who previously sustained Grades II-IIIb open tibial fractures had an average bony defect of 9 cm. Two patients had previous bony infections. All patients had had serial debridements and myocutaneous flaps were required in three patients. An unreamed IM nail was inserted, and the transport device was applied. After an osteotomy, segmental transport was carried out until docking was achieved. The external fixator was removed after interlocking of the transported segment. The mean duration of external fixation was 17.9 days/cm and the mean period until roentgenographic consolidation of the distraction and nonunion site was 41.2 days/cm. There were two pin-tract infections but no IM infections. One nail broke after osseous consolidation of the regenerate at the distal interlocking site and required exchange. The goal of transport was achieved in all cases without angular or rotational deformity or length discrepancy. There were no neurovascular injuries.", "author" : [ { "dropping-particle" : "", "family" : "Raschke", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mann", "given" : "J W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oedekoven", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Claudi", "given" : "B F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-1", "issue" : "282", "issued" : { "date-parts" : [ [ "1992", "9" ] ] }, "page" : "233-40", "title" : "Segmental transport after unreamed intramedullary nailing. Preliminary report of a \"Monorail\" system.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0021-9355", "PMID" : "9378732", "abstract" : "Twenty-nine patients (thirty-two femora) had femoral lengthening over an intramedullary nail, with the nail and the external fixator applied concomitantly at the time of the femoral osteotomy. After gradual distraction at a rate of one millimeter per day, the nail was locked and the fixator was removed. The mean age was twenty-six years (range, ten to fifty-three years), and the mean amount of lengthening was 5.8 centimeters (range, two to thirteen centimeters). For comparison, thirty-one patients (thirty-two limbs) who had had standard Ilizarov femoral lengthening were matched with the group that had had lengthening over an intramedullary nail; the matching was performed on the basis of the amount of lengthening, the age of the patient, the etiology of the indication for lengthening, and the level of difficulty of the procedure. Lengthening over an intramedullary nail reduced the average duration of external fixation by almost one-half. The radiographic consolidation index (the number of months needed for radiographic consolidation for each centimeter of lengthening) for the limbs that had had lengthening over an intramedullary nail was reduced significantly (p < 0.001) compared with that for the matched-case group. The range of motion of the knee returned to normal a mean of 2.2 times faster in the group that had had lengthening over an intramedullary nail. There were six refractures of the distraction bone in the matched-case group. In the group that had had lengthening over an intramedullary nail, one nail and one proximal locking screw failed. The over-all rate of complications was 1.4 per cent in the group that had had lengthening over an intramedullary nail compared with 1.9 per cent in the matched-case group. With the numbers of patients available for study, we could not detect a significant difference between the groups with respect to the operative time (p = 0.124); however, the cost of treatment and the estimated blood loss were higher in the group that had had lengthening over an intramedullary nail. On the basis of clinical and radiographic criteria, there were twenty-three excellent, seven good, and two fair results in the group that had had lengthening over an intramedullary nail compared with twenty-six excellent, four good, and two fair results in the matched-case group (p = 0.37). The advantages of lengthening over an intramedullary nail include a decrease in the duration of external fixation, protection against refracture, and earlier\u2026", "author" : [ { "dropping-particle" : "", "family" : "Paley", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Herzenberg", "given" : "J E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Paremain", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bhave", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. American volume", "id" : "ITEM-2", "issue" : "10", "issued" : { "date-parts" : [ [ "1997", "10" ] ] }, "page" : "1464-80", "title" : "Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening.", "type" : "article-journal", "volume" : "79" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "0020-1383", "PMID" : "10707207", "author" : [ { "dropping-particle" : "", "family" : "Li", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Athanasou", "given" : "N A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Injury", "id" : "ITEM-3", "issue" : "8", "issued" : { "date-parts" : [ [ "1999", "10" ] ] }, "page" : "525-34", "title" : "Bone transport over an intramedullary nail. A case report with histologic examination of the regenerated segment.", "type" : "article-journal", "volume" : "30" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "ISSN" : "0301-620X", "PMID" : "10615983", "abstract" : "Distraction osteogenesis is widely used for leg lengthening, but often requires a long period of external fixation which carries risks of pin-track sepsis, malalignment, stiffness of the joint and late fracture of the regenerate. We present the results of 20 cases in which, in an attempt to reduce the rate of complications, a combination of external fixation and intramedullary nailing was used. The mean gain in length was 4.7 cm (2 to 8.6). The mean time of external fixation was 20 days per centimetre gain in length. All distracted segments healed spontaneously without refracture or malalignment. There were three cases of deep infection, two of which occurred in patients who had had previous open fractures of the bone which was being lengthened. All resolved with appropriate treatment. This method allows early rehabilitation, with a rapid return of knee movement. There is a lower rate of complications than occurs when external fixation is used on its own. The time of external fixation is shorter than in other methods of leg lengthening. The high risk of infection calls for caution.", "author" : [ { "dropping-particle" : "", "family" : "Simpson", "given" : "A H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cole", "given" : "A S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kenwright", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-4", "issue" : "6", "issued" : { "date-parts" : [ [ "1999", "11" ] ] }, "page" : "1041-5", "title" : "Leg lengthening over an intramedullary nail.", "type" : "article-journal", "volume" : "81" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[118\u2013121]", "plainTextFormattedCitation" : "[118\u2013121]", "previouslyFormattedCitation" : "[118\u2013121]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[118–121]. There are reports of the subsequent lengthening being performed acutely followed by plating or nailing ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0301-620X", "PMID" : "8331110", "abstract" : "One-stage femoral lengthening is thought to have an unacceptably high complication rate and is not widely practised. We reviewed 17 patients after one-stage lengthening for femoral shortening with associated angular or rotational deformities. Minimal dissection of the bone ends was undertaken. The mean length gain was 4 cm (2 to 7), and the average time to union was 6 months (3 to 10). There were no neurovascular complications. Four patients had delayed or nonunion, but union was achieved after bone grafting. We conclude that with minimal dissection, and with iliac crest cancellous bone grafting, one-stage leg lengthening for correction of deformity and leg-length inequality of up to 7 cm, in selected patients, can be effected safely with a relatively short rehabilitation.", "author" : [ { "dropping-particle" : "", "family" : "Murray", "given" : "D W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kambouroglou", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kenwright", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "1993", "7" ] ] }, "page" : "566-71", "title" : "One-stage lengthening for femoral shortening with associated deformity.", "type" : "article-journal", "volume" : "75" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0021-9355", "PMID" : "8126043", "abstract" : "Forty-nine skeletally mature patients who had either a non-union or a malunion of a fracture of the tibia or the femur had correction of the deformity and acute axial lengthening of the fractured bone. Distraction was provided by the short AO/ASIF fracture distractor applied directly to the site of the osteotomy or non-union. At an average of sixty-three months (range, twenty-six to 105 months), the average increase in the tibial and femoral length was 1.7 and 3.2 centimeters, respectively. There were no compartment syndromes or ischemia secondary to any of the procedures. One patient had a transient sensory-nerve loss. Fatigue fractures were seen in two tibial plates, two femoral plates, and one femoral intramedullary nail used for osteosynthesis. A non-union developed after four other femoral intramedullary nailing procedures. One infection developed after lengthening of a tibia. Restoration of normal length by acute lengthening and internal fixation was achieved in twenty-seven patients. One patient had overlengthening of one centimeter. Fifteen patients had residual shortening of approximately one centimeter, three had shortening of more than one to 2.5 centimeters, and three patients had more than 2.5 centimeters of shortening. The patients in this series had acute restoration of limb length after traumatic shortening with a low prevalence of complications of neurovascular compromise. Three of the thirty tibial lengthenings and seven of the nineteen femoral lengthenings had to be followed by at least one additional procedure to obtain union.", "author" : [ { "dropping-particle" : "", "family" : "Johnson", "given" : "E E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. American volume", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "1994", "3" ] ] }, "page" : "379-89", "title" : "Acute lengthening of shortened lower extremities after malunion or non-union of a fracture.", "type" : "article-journal", "volume" : "76" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[122,123]", "plainTextFormattedCitation" : "[122,123]", "previouslyFormattedCitation" : "[122,123]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[122,123] but the length regained by this method is limited, with an average of 4 cm, and despite supplementary bone graft being used, nonunion and delayed union are significant risks. Overall, bone shortening and subsequent lengthening is associated with a lower complication rate than bone transport techniquesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-921X", "PMID" : "2912628", "abstract" : "To assess the influence of both the rate and the frequency of distraction on osteogenesis during limb elongation, a canine tibia was used with various combinations of distraction rates (0.5 mm, 1.0 mm, or 2.0 mm per day) and distraction frequencies (one step per day, four steps per day, 60 steps per day). The distractions were performed after both open osteotomy and closed osteoclasis. Histomorphic and biochemical studies were conducted on the elongated osseous tissue, fascia, skeletal muscle, smooth muscle, blood vessels, nerves, and skin. It was determined that distraction at a rate of 0.5 mm per day often led to premature consolidation of the lengthening bone, while a distraction rate of 2.0 mm per day often resulted in undesirable changes within elongating tissues. A distraction rate of 1.0 mm per day led to the best results. It was also observed that the greater the distraction frequency, the better the outcome. With optimum preservation of periosseous tissues, bone marrow, and blood supply at the time of osteotomy, stability of external fixation, and 1.0 mm per day of distraction in four steps, osteogenesis within the distraction gap of an elongating bone takes place by the formation of a physislike structure, in which new bone forms in parallel columns extending in both directions from a central growth zone. The growth plate that forms under the influence of tension-stress has features of both physeal and intramembranous ossification, yet is neither; instead, the distraction regenerated bone is unique, providing numerous applications in clinical traumatology, orthopedics, and other medical disciplines.", "author" : [ { "dropping-particle" : "", "family" : "Ilizarov", "given" : "G A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-1", "issue" : "239", "issued" : { "date-parts" : [ [ "1989", "2" ] ] }, "page" : "263-85", "title" : "The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0009-921X", "PMID" : "2910611", "abstract" : "To evaluate the optimum conditions for osteogenesis during limb lengthening and to study the changes in soft tissues undergoing elongation, a series of experiments were performed on the canine tibia. The experiments used the transfixion-wire, Ilizarov circular external skeletal fixator in configurations of differing stability of fixation in combination with a second variable, i.e., preservation of the periosteum, bone marrow, and medullary blood supply. Both increased fixator stability, and maximum preservation of the periosseous and intraosseous soft tissues enhanced bone formation during limb lengthening. To assess the role that the direction of the elongation vector plays in osteogenesis, canine tibiae were widened rather than lengthened in a second series of experiments using an Ilizarov apparatus modified for lateral distraction. The new bone formed parallel to the tension vector even when perpendicular to the bone's mechanical axis. As in longitudinal lengthening, damage to the bone marrow inhibits osteogenesis occurring by the influence of a lateral tension-stress vector. In a third series of experiments, half- and full-circumference cortical defects were created in canine tibiae to study the osteogenic potential of the marrow. New bone formed rapidly, even when the marrow was separated from the surrounding periosseous soft tissues by a sheet of polyvinyl chloride, attesting to the importance of marrow element preservation during osteotomy for limb lengthening.", "author" : [ { "dropping-particle" : "", "family" : "Ilizarov", "given" : "G A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical orthopaedics and related research", "id" : "ITEM-2", "issue" : "238", "issued" : { "date-parts" : [ [ "1989", "1" ] ] }, "page" : "249-81", "title" : "The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "0301-620X", "PMID" : "2005164", "abstract" : "We report our experience of the use of the Ilizarov technique to treat nine patients with severe compound tibial fractures. The mean defect in bone was 6.3 cm, and four cases were infected. All nine patients had satisfactory union and function without the use of bone grafts or antibiotics. The Ilizarov technique was very satisfactory; there were no major complications.", "author" : [ { "dropping-particle" : "", "family" : "Dagher", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roukoz", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "1991", "3" ] ] }, "page" : "316-21", "title" : "Compound tibial fractures with bone loss treated by the Ilizarov technique.", "type" : "article-journal", "volume" : "73" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "ISSN" : "0301-620X", "PMID" : "7744930", "abstract" : "We report the results in the first 16 patients treated in Sheffield using bifocal techniques for diaphyseal bone loss and deformity secondary to trauma. Eight patients had bone-transport and eight had compression-distraction methods. At a mean follow-up of 24 months all 16 had excellent or good results with union of the fracture, correction of deformity and normal or near normal leg length. There were no major complications. Mean treatment times were 16 months for bone transport and 9.8 months for compression-distraction. Bone transport was more complicated requiring an average of 2.2 additional operations compared with only one for compression-distraction. Femoral cases had shorter treatment indices than tibial cases but had less favourable outcomes.", "author" : [ { "dropping-particle" : "", "family" : "Saleh", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rees", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of bone and joint surgery. British volume", "id" : "ITEM-4", "issue" : "3", "issued" : { "date-parts" : [ [ "1995", "5" ] ] }, "page" : "429-34", "title" : "Bifocal surgery for deformity and bone loss after lower-limb fractures. Comparison of bone-transport and compression-distraction methods.", "type" : "article-journal", "volume" : "77" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[124\u2013127]", "plainTextFormattedCitation" : "[124\u2013127]", "previouslyFormattedCitation" : "[124\u2013127]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[124–127]. (d) AmputationAlthough amputation is seldom regarded as a palatable option by either patient or surgeon, it may be a wise choice in some situations. Some patients may be poor candidates to undergo a prolonged reconstructive procedure involving limb lengthening or bone transport for social or medical reasons. Various other general factors need to be taken into accountADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1056/NEJMoa012604", "ISSN" : "1533-4406", "PMID" : "12477942", "abstract" : "BACKGROUND: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated.\n\nMETHODS: We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization.\n\nRESULTS: At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively).\n\nCONCLUSIONS: Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.", "author" : [ { "dropping-particle" : "", "family" : "Bosse", "given" : "Michael J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacKenzie", "given" : "Ellen J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kellam", "given" : "James F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burgess", "given" : "Andrew R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Webb", "given" : "Lawrence X", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Swiontkowski", "given" : "Marc F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sanders", "given" : "Roy W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jones", "given" : "Alan L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McAndrew", "given" : "Mark P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patterson", "given" : "Brendan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCarthy", "given" : "Melissa L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Travison", "given" : "Thomas G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Castillo", "given" : "Renan C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The New England journal of medicine", "id" : "ITEM-1", "issue" : "24", "issued" : { "date-parts" : [ [ "2002", "12", "12" ] ] }, "page" : "1924-31", "title" : "An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.", "type" : "article-journal", "volume" : "347" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[128]", "plainTextFormattedCitation" : "[128]", "previouslyFormattedCitation" : "[128]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[128]. Elderly patients or patients with other risk factors such as smoking, alcohol abuse, steroid treatment, diabetes and occlusive arterial disease, may be better advised to accept amputation rather than risk a prolonged attempt at limb reconstruction with multiple surgical interventions and a high rate of complication. The available evidence suggests that in patients with severe limb injury the functional outcome and the chance of returning to work is no different with amputation or limb salvageADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1056/NEJMoa012604", "ISSN" : "1533-4406", "PMID" : "12477942", "abstract" : "BACKGROUND: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated.\n\nMETHODS: We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization.\n\nRESULTS: At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively).\n\nCONCLUSIONS: Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.", "author" : [ { "dropping-particle" : "", "family" : "Bosse", "given" : "Michael J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacKenzie", "given" : "Ellen J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kellam", "given" : "James F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burgess", "given" : "Andrew R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Webb", "given" : "Lawrence X", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Swiontkowski", "given" : "Marc F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sanders", "given" : "Roy W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jones", "given" : "Alan L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McAndrew", "given" : "Mark P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patterson", "given" : "Brendan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCarthy", "given" : "Melissa L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Travison", "given" : "Thomas G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Castillo", "given" : "Renan C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The New England journal of medicine", "id" : "ITEM-1", "issue" : "24", "issued" : { "date-parts" : [ [ "2002", "12", "12" ] ] }, "page" : "1924-31", "title" : "An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.", "type" : "article-journal", "volume" : "347" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[128]", "plainTextFormattedCitation" : "[128]", "previouslyFormattedCitation" : "[128]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[128].ConclusionThe majority of infected nonunions following IM nailing can be treated with exchange nailing. However, patients should be warned of the likelihood of needing several exchange nailing procedures to achieve union. The median time to union of staged exchange nail procedures is similar to time required to obtain union if an Ilizarov procedure had been carried out instead of the exchange nailing proceduresADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Tsang", "given" : "STJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mills", "given" : "Leanora Anne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baren", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frantzias", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keating", "given" : "J F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simpson", "given" : "A Hamish R W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bone and joint journal", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2016" ] ] }, "page" : "534-541", "title" : "Exchange nailing for nonunion of diaphyseal fractures of the tibia. Our results and an analysis of the risk factors for failure", "type" : "article-journal", "volume" : "98 B" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[24]", "plainTextFormattedCitation" : "[24]", "previouslyFormattedCitation" : "[24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[24]. However, exchange nailing is less likely to be successful in patients who have nonunions (1) without any periosteal reaction at the fracture site, (2) without a known readily treatable bacteria and (3) with a bone defect. Patients with nonunions with these features should be treated with excision of the non-union and acute shortening or a staged protocol with adjuvant local antibiotic therapy and subsequent reconstruction with an induced membrane technique or an Ilizarov distraction osteogenesis procedure (Fig. 3).BibliographyADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY [1]Egol KA, Gruson K, Spitzer AB, Walsh M, Tejwani NC. Do Successful Surgical Results after Operative Treatment of Long-bone Nonunions Correlate with Outcomes? Clin Orthop Relat Res 2009;467:2979–85..[2]Barker KL, Lamb SE, Simpson AHRW. Functional recovery in patients with nonunion treated with the Ilizarov technique. J Bone Joint Surg Br 2004;86:81–5.[3]Kanakaris NK, Calori GM, Verdonk R, Burssens P, De Biase P, Capanna R, et al. Application of BMP-7 to tibial non-unions: A 3-year multicenter experience. Inj J Care Inj 2008;39:S83–90. [4]Patil S, Montgomery R. Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications. J Bone Jt Surgery-British Vol 2006;88B:928–32. [5]Dahabreh Z, Calori GM, Kanakaris NK, Nikolaou VS, Giannoudis P V. A cost analysis of treatment of tibial fracture nonunion by bone grafting or bone morphogenetic protein-7. Int Orthop 2009;33:1407–14. [6]Dahabreh Z, Dimitriou R, Giannoudis P V. Health economics: A cost analysis of treatment of persistent fracture non-unions using bone morphogenetic protein-7. Inj J Care Inj 2007;38:371–7.[7]Mills LA, Simpson AHRW. The relative incidence of fracture non-union in the Scottish population (5.17 million): a 5-year epidemiological study. BMJ Open 2013;3. [8]Mills L, Tsang S, Hooper G, Keenan G, Simpson A. The multifactorial aetiology of fracture non-union and the importance of searching for latent infection. Bone Joint Res 2016;In-press.[9]Court-Brown C, McQueen M, Tornetta III P. Trauma. Orthopaedic surgery essentials. 1st ed. Philadelphia: Lippincott Williams and Wilkins; 2006.[10]Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24:742–6.[11]Lin J, Hou SM, Hang YS, Chao EY. Treatment of humeral shaft fractures by retrograde locked nailing. Clin Orthop Relat Res 1997:147–55.[12]Lin J, Hou SM. 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[29]Lalidou F, Kolios G, Tavridou A, Drosos GI. Bone grafts as carriers for local antibiotic delivery for the treatment and prevention of bone infections. Surg Technol Int 2014;25:239–45.[30]Giannoudis P V. Treatment of bone defects: Bone transport or the induced membrane technique? Injury 2016;47:291–2. [31]Gaston MS, Simpson AHRW. Inhibition of fracture healing. J Bone Jt Surgery-British Vol 2007;89B:1553–60. [32]Swanson EA, Garrard EC, O?Connor DP, Brinker MR. Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions. J Orthop Trauma 2015;29:28–35. [33]Swanson EA, Garrard EC, Bernstein DT, O’Connor DP, Brinker MR. The Results of a Systematic Approach to Exchange Nailing for the Treatment of Aseptic Femoral Nonunions. J Orthop Trauma 2014;29:21–7. [34]Calori GM, Phillips M, Jeetle S, Tagliabue L, Giannoudis P V. Classification of non-union: Need for a new scoring system? Inj J Care Inj 2008;39:S59–63. [35]Donlan RM. 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[48]Leung AHC, Hawthorn BR, Simpson AHRW. The Effectiveness of Local Antibiotics in Treating Chronic Osteomyelitis in a Cohort of 50 Patients with an Average of 4 Years Follow-Up. Open Orthop J 2015;9:372–8. [49]Rand BCC, Penn-Barwell JG, Wenke JC. Combined local and systemic antibiotic delivery improves eradication of wound contamination: An animal experimental model of contaminated fracture. Bone Joint J 2015;97–B:1423–7. d[50]Fleiter N, Walter G, B?sebeck H, Vogt S, Büchner H, Hirschberger W, et al. Clinical use and safety of a novel gentamicin-releasing resorbable bone graft substitute in the treatment of osteomyelitis/osteitis. Bone Joint Res 2014;3:223–9. [51]Romanò CL, Logoluso N, Meani E, Romanò D, De Vecchi E, Vassena C, et al. A comparative study of the use of bioactive glass S53P4 and antibiotic-loaded calcium-based bone substitutes in the treatment of chronic osteomyelitis: a retrospective comparative study. Bone Joint J 2014;96–B:845–50. 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