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Infected Nonunion of the Upper Extremity
EVIDENCE-BASED MEDICINE
Evidence-Based Medicine
Infected Nonunion of the Upper Extremity Abhishek Julka, MD, Kagan Ozer, MD THE PATIENT A 55-year-old man had a mid-diaphyseal segmental fracture of the humerus after a fall onto his dominant right hand. He has type 2 diabetes and chronic alcoholism, and he smokes. The fractures were treated with functional bracing. Six months after injury, neither fracture was healed. After 3 surgeries for plate fixation and autogeneous cancellous bone grafting over a 22-month period, he was diagnosed with a methicillin-resistant Staphylococcus aureus (MRSA) infection. Following implant removal, external fixation, serial debridement with antibiotic-impregnated cement spacer placement and 6 weeks of intravenous vancomycin, his C-reactive protein and erythrocyte sedimentation rate return to normal, and he has shown no signs of infection for 3 months. There is an 8-cm bony defect. THE QUESTION What is the best management for an upper extremity nonunion with defect after infection? CURRENT OPINION Nonunions of the upper extremity after infection pose the dual challenge of eradicating infection while trying to obtain union in an unfavorable environment. Issues include soft tissue damage from open fractures and prior surgery, bone loss, loosening or breakage of internal fixation, and multiple medical comorbidities.1– 4 The infection is treated with removal of all foreign material and devitalized tissue followed by parenteral antibiotics. Some surgeons use antibiotic-impregnated methylmethacrylate spacers to maintain a space to address bone defects at subsequent surgeries.5 Operative treatment consists of internal fixation, bone graft, and soft tissue reconstruction as needed. The bony defect can be addressed by shortening, nonvascularized canFrom the Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan. Received for publication March 13, 2013; accepted in revised form March 28, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:KaganOzer,MD,OrthopedicsatSouthMain,2098S.MainSt.,AnnArbor, MI 48103; e-mail: [email protected]. 0363-5023/13/38A11-0029$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.03.061
2244 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
cellous or corticocancellous bone grafts, or vascularized bone grafts. The general rule is to use nonvascularized bone grafts for defects up to 5 cm and vascularized grafts (often from the fibula) for larger defects. Another option is bone transport with distraction osteogenesis.6 THE EVIDENCE Host factors In a study of host factors and their effect on infection risk following an open fracture, Bowen and Widmaier1 found patients with 3 or more immune system compromising factors and an open fracture to have a 30% incidence of infection. In addition, tobacco use has independently been shown to increase risk of nonunion and infection.7 In a study of patients with unexplained nonunions, Brinker et al8 found 31 of 37 patients to have endocrine or metabolic abnormalities. Vascularized bone graft Adani et al9 reviewed 10 patients with an average forearm bone defect of 8.4 cm after debridement of osteomyelitis treated with a vascularized fibula graft. Patients had undergone 4 previous surgeries on average. The authors achieved union in 9 of 10 patients at 4.8 months. Functional outcomes as determined by the Tang system were 4 excellent, 2 good, 2 fair, and 1 poor. Mattar et al10 treated infected nonunions of 11 radii, 2 humeri, and 1 ulna with an average 9-cm bony defect after debridement using a vascularized fibula graft. Radiographic healing, resolution of infection, and good clinical outcomes occurred in 13 of 14 patients (93%). Jupiter et al11 treated 6 patients with infected nonunion of the radius with an average bone loss of 7.9 cm after debridement and associated soft tissue problems with an osteoseptocutaneous vascularized fibula graft. Five patients (83%) achieved union with 1 patient having an asymptomatic nonunion at the distal graft-host junction. At an average follow-up of 24 months, no patients demonstrated any signs of infection. Dell and Sheppard12 created a 1-bone forearm using a vascularized free fibula graft secured to the ulna proximally and the radius distally with supplementary iliac crest bone graft placed at junction sites in 4 patients with large defects after debridement of osteomy-
elitis. All patients united, 3 within 4 months and 1 at 8 months after secondary cancellous bone grafting at the proximal graft–native bone junction. Saint-Cyr and colleagues13 performed a double-barrel vascularized free fibula graft in 2 patients with 6 cm of bone loss of both the radius and the ulna after debridement of osteomyelitis. All patients healed without relapse of infection at final follow-up. Pinal et al14 treated 2 patients with ulna nonunions with 2 to 3 cm of bone loss after debridement using vascularized medial femoral condyle corticoperiosteal grafts. Both fractures healed by 3 months with no infection. Nonvascularized autogenous bone graft Ring and Jupiter15 described the use of wave plate osteosynthesis for forearm and humerus nonunions with a well vascularized muscular envelope. Autogenous cancellous bone graft is placed in the defect site and beneath a bend in the plate. In 5 of 14 patients, the bone defect was related in part to debridement of osteomyelitis. All patients healed after the procedure. Allende16 treated 20 patients with upper extremity nonunions with defects ranging from 1 to 6 cm after debridement of osteomyelitis using cancellous bone grafting and plate and screw fixation after initial temporary placement of a gentamycin/vancomycin-impregnated cement spacer placement with the aim of development of a pseudomembrane (Masqualet technique). All of the nonunions healed without further signs of infection at an average of 5 months. Georgiadis and DeSilva17 treated 4 forearm nonunions with a bone defect after debridement of osteomyelitis using a similar technique. Three patients with an average defect of 4 cm united and 1 patient with a 12-cm defect did not. Chen et al18 achieved union in 12 of 14 patients with humeral nonunions and bone defect after debridement of infection treated with a similar technique. Bone transport Pullen et al19 treated 3 patients with infected humeral diaphysis nonunion with 6-, 7-, and 11-cm defects with bone transport. Resolution of infection and union were achieved in all patients with 6.6 months of Ilizarov external fixation. One patient required cancellous bone grafting, 1 fractured through regenerate bone, and 1 had 2 fractures through the nonunion site after fixator removal. One patient attained normal humeral length and 2 had 1 and 3 cm of humeral shortening, respectively. Esser20 achieved union with bone transport in an infected ulna nonunion with an 8-cm defect. The uni-
2245
lateral external fixator was removed at 10 months with no resulting ulnar shortening. Al-Sayyad21 achieved union using the Ilizarov technique in an infected radius nonunion with a 4-cm bone defect treated with bone transport. Initially, debridement was performed followed by a 6-week intravenous antibiotic course. After 43 weeks in the frame, the patient achieved union and returned to performing activities of daily living. Shortcomings of the evidence Nonunions of the upper extremity with bony defect after debridement of osteomyelitis are difficult to study because they are uncommon and present with variable bone loss and soft tissue coverage. The diagnosis of nonunion and infection are not standardized. Data are limited to case reports and small retrospective case series that are difficult to compare. DIRECTIONS FOR FUTURE RESEARCH We need valid and reliable methods for diagnosing resolution of infection. Studies that would provide useful data to inform the management of patients with nonunions after infection include (1) basic science studies differentiating healing in the presence and absence of infection and (2) randomized clinical trials comparing bone reconstruction techniques. Trials would need to involve multiple centers because these problems are rare, address donor site morbidity, and address cost. OUR CURRENT CONCEPTS FOR THIS PATIENT We filled the bony defect with a vascularized fibular transfer because of the size of the defect, the ability of a structural graft to share load, and its potential to resist infection. We did not remove the pseudomembrane formed around the cement spacer. We stabilized the nonunion with a plate and screws. There were radiographic signs of healing 6 months after surgery. The infection has not recurred in 2 years. We prefer vascularized fibular transfer to bone transport because external fixation is cumbersome and prone to pin-site complications. We prefer this approach to autogenous cancellous grafting because the structural graft can help share the load. REFERENCES 1. Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205–211. 2. Dellinger EP, Miller SD, Wertz MJ, Grypma M, Droppert B, Anderson PA. Risk of infection after open fracture of the arm or leg. Arch Surg. 1988;123(11):1320 –1327. 3. Jain AK, Sinha S. Infected nonunion of the long bones. Clin Orthop Relat Res. 2005;431:57– 65.
JHS 䉬 Vol A, November
Evidence-Based Medicine
INFECTED NONUNION OF THE UPPER EXTREMITY
2246
INFECTED NONUNION OF THE UPPER EXTREMITY
Evidence-Based Medicine
4. Forsberg JA, Potter BK, Cierny G, Webb L. Diagnosis and management of chronic infection. J Am Acad Orthop Surg. 2011;19(Suppl 1):S8–S19. 5. Struijs PA, Poolman RW, Bhandari M. Infected nonunion of the long bones. J Orthop Trauma. 2007;21(7):507–511. 6. Brinker MR, O’Connor DP. Nonunions: evaluation and treatment. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma. Philadelphia, PA: WB Saunders; 2009:615–706. 7. Harvey EJ, Agel J, Selznick HS, Chapman JR, Henley MB. Deleterious effect of smoking on healing of open tibia-shaft fractures. Am J Orthop (Belle Mead NJ). 2002;31(9):518 –521. 8. Brinker MR, O Connor DP, Monla YT, Earthman TP. Metabolic and endocrine abnormalities in patients with nonunions. J Hand Surg Am. 2007;21(8):557–570. 9. Adani R, Delcroix L, Innocenti M, et al. Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft. Microsurgery. 2004;24(6):423– 429. 10. Mattar R Jr, Azze RJ, Ferreira MC, Starck R, Canedo AC. Vascularized fibular graft for management of severe osteomyelitis of the upper extremity. Microsurgery. 1994;15(1):22–27. 11. Jupiter JB, Gerhard HJ, Guerrero J, Nunley JA, Levin LS. Treatment of segmental defects of the radius with use of the vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg Am. 1997;79(4):542–550. 12. Dell PC, Sheppard JE. Vascularized bone grafts in the treatment of infected forearm nonunions. J Hand Surg Am. 1984;9(5):653– 658.
13. Saint-Cyr M, Farkas J, Gupta A. Double-barrel free fibula flap for treatment of infected nonunion of both forearm bones. J Reconstr Microsurg. 2008;24(8):583–587. 14. Pinal FD, García-Bernal FD, Regalado J, Ayala H, Cagigal L, Studer A. Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb. J Hand Surg Eur Vol. 2007;32(2):135–142. 15. Ring D, Jupiter JB. Wave plate osteosynthesis in the upper extremity. Tech Hand Up Extrem Surg. 1997;1(3):168 –174. 16. Allende C. Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity. Tech Hand Up Extrem Surg. 2010;14(4):241–247. 17. Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm after trauma: treatment with cement spacer and delayed cancellous bone grafting. J Trauma. 1995;38(6):910 –914. 18. Chen CY, Ueng SW, Shih CH. Staged management of infected humeral nonunion. J Trauma. 1997;43(5):793–798. 19. Pullen C, Manzotti A, Catagni MA, Guerreschi F. Treatment of post-traumatic humeral diaphyseal nonunion with bone loss. J Shoulder Elbow Surg. 2003;12(5):436 – 441. 20. Esser RD. Treatment of a bone defect of the forearm by bone transport. A case report. Clin Orthop Relat Res. 1996;326:221–224. 21. Al-Sayyad MJ. Taylor spatial frame in the treatment of upper extremity conditions. J Pediatr Orthop. 2012;32(2):169 –178.
JHS 䉬 Vol A, November
Evidence-Based Medicine
Infected Nonunion of the Upper Extremity Abhishek Julka, MD, Kagan Ozer, MD THE PATIENT A 55-year-old man had a mid-diaphyseal segmental fracture of the humerus after a fall onto his dominant right hand. He has type 2 diabetes and chronic alcoholism, and he smokes. The fractures were treated with functional bracing. Six months after injury, neither fracture was healed. After 3 surgeries for plate fixation and autogeneous cancellous bone grafting over a 22-month period, he was diagnosed with a methicillin-resistant Staphylococcus aureus (MRSA) infection. Following implant removal, external fixation, serial debridement with antibiotic-impregnated cement spacer placement and 6 weeks of intravenous vancomycin, his C-reactive protein and erythrocyte sedimentation rate return to normal, and he has shown no signs of infection for 3 months. There is an 8-cm bony defect. THE QUESTION What is the best management for an upper extremity nonunion with defect after infection? CURRENT OPINION Nonunions of the upper extremity after infection pose the dual challenge of eradicating infection while trying to obtain union in an unfavorable environment. Issues include soft tissue damage from open fractures and prior surgery, bone loss, loosening or breakage of internal fixation, and multiple medical comorbidities.1– 4 The infection is treated with removal of all foreign material and devitalized tissue followed by parenteral antibiotics. Some surgeons use antibiotic-impregnated methylmethacrylate spacers to maintain a space to address bone defects at subsequent surgeries.5 Operative treatment consists of internal fixation, bone graft, and soft tissue reconstruction as needed. The bony defect can be addressed by shortening, nonvascularized canFrom the Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan. Received for publication March 13, 2013; accepted in revised form March 28, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:KaganOzer,MD,OrthopedicsatSouthMain,2098S.MainSt.,AnnArbor, MI 48103; e-mail: [email protected]. 0363-5023/13/38A11-0029$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.03.061
2244 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
cellous or corticocancellous bone grafts, or vascularized bone grafts. The general rule is to use nonvascularized bone grafts for defects up to 5 cm and vascularized grafts (often from the fibula) for larger defects. Another option is bone transport with distraction osteogenesis.6 THE EVIDENCE Host factors In a study of host factors and their effect on infection risk following an open fracture, Bowen and Widmaier1 found patients with 3 or more immune system compromising factors and an open fracture to have a 30% incidence of infection. In addition, tobacco use has independently been shown to increase risk of nonunion and infection.7 In a study of patients with unexplained nonunions, Brinker et al8 found 31 of 37 patients to have endocrine or metabolic abnormalities. Vascularized bone graft Adani et al9 reviewed 10 patients with an average forearm bone defect of 8.4 cm after debridement of osteomyelitis treated with a vascularized fibula graft. Patients had undergone 4 previous surgeries on average. The authors achieved union in 9 of 10 patients at 4.8 months. Functional outcomes as determined by the Tang system were 4 excellent, 2 good, 2 fair, and 1 poor. Mattar et al10 treated infected nonunions of 11 radii, 2 humeri, and 1 ulna with an average 9-cm bony defect after debridement using a vascularized fibula graft. Radiographic healing, resolution of infection, and good clinical outcomes occurred in 13 of 14 patients (93%). Jupiter et al11 treated 6 patients with infected nonunion of the radius with an average bone loss of 7.9 cm after debridement and associated soft tissue problems with an osteoseptocutaneous vascularized fibula graft. Five patients (83%) achieved union with 1 patient having an asymptomatic nonunion at the distal graft-host junction. At an average follow-up of 24 months, no patients demonstrated any signs of infection. Dell and Sheppard12 created a 1-bone forearm using a vascularized free fibula graft secured to the ulna proximally and the radius distally with supplementary iliac crest bone graft placed at junction sites in 4 patients with large defects after debridement of osteomy-
elitis. All patients united, 3 within 4 months and 1 at 8 months after secondary cancellous bone grafting at the proximal graft–native bone junction. Saint-Cyr and colleagues13 performed a double-barrel vascularized free fibula graft in 2 patients with 6 cm of bone loss of both the radius and the ulna after debridement of osteomyelitis. All patients healed without relapse of infection at final follow-up. Pinal et al14 treated 2 patients with ulna nonunions with 2 to 3 cm of bone loss after debridement using vascularized medial femoral condyle corticoperiosteal grafts. Both fractures healed by 3 months with no infection. Nonvascularized autogenous bone graft Ring and Jupiter15 described the use of wave plate osteosynthesis for forearm and humerus nonunions with a well vascularized muscular envelope. Autogenous cancellous bone graft is placed in the defect site and beneath a bend in the plate. In 5 of 14 patients, the bone defect was related in part to debridement of osteomyelitis. All patients healed after the procedure. Allende16 treated 20 patients with upper extremity nonunions with defects ranging from 1 to 6 cm after debridement of osteomyelitis using cancellous bone grafting and plate and screw fixation after initial temporary placement of a gentamycin/vancomycin-impregnated cement spacer placement with the aim of development of a pseudomembrane (Masqualet technique). All of the nonunions healed without further signs of infection at an average of 5 months. Georgiadis and DeSilva17 treated 4 forearm nonunions with a bone defect after debridement of osteomyelitis using a similar technique. Three patients with an average defect of 4 cm united and 1 patient with a 12-cm defect did not. Chen et al18 achieved union in 12 of 14 patients with humeral nonunions and bone defect after debridement of infection treated with a similar technique. Bone transport Pullen et al19 treated 3 patients with infected humeral diaphysis nonunion with 6-, 7-, and 11-cm defects with bone transport. Resolution of infection and union were achieved in all patients with 6.6 months of Ilizarov external fixation. One patient required cancellous bone grafting, 1 fractured through regenerate bone, and 1 had 2 fractures through the nonunion site after fixator removal. One patient attained normal humeral length and 2 had 1 and 3 cm of humeral shortening, respectively. Esser20 achieved union with bone transport in an infected ulna nonunion with an 8-cm defect. The uni-
2245
lateral external fixator was removed at 10 months with no resulting ulnar shortening. Al-Sayyad21 achieved union using the Ilizarov technique in an infected radius nonunion with a 4-cm bone defect treated with bone transport. Initially, debridement was performed followed by a 6-week intravenous antibiotic course. After 43 weeks in the frame, the patient achieved union and returned to performing activities of daily living. Shortcomings of the evidence Nonunions of the upper extremity with bony defect after debridement of osteomyelitis are difficult to study because they are uncommon and present with variable bone loss and soft tissue coverage. The diagnosis of nonunion and infection are not standardized. Data are limited to case reports and small retrospective case series that are difficult to compare. DIRECTIONS FOR FUTURE RESEARCH We need valid and reliable methods for diagnosing resolution of infection. Studies that would provide useful data to inform the management of patients with nonunions after infection include (1) basic science studies differentiating healing in the presence and absence of infection and (2) randomized clinical trials comparing bone reconstruction techniques. Trials would need to involve multiple centers because these problems are rare, address donor site morbidity, and address cost. OUR CURRENT CONCEPTS FOR THIS PATIENT We filled the bony defect with a vascularized fibular transfer because of the size of the defect, the ability of a structural graft to share load, and its potential to resist infection. We did not remove the pseudomembrane formed around the cement spacer. We stabilized the nonunion with a plate and screws. There were radiographic signs of healing 6 months after surgery. The infection has not recurred in 2 years. We prefer vascularized fibular transfer to bone transport because external fixation is cumbersome and prone to pin-site complications. We prefer this approach to autogenous cancellous grafting because the structural graft can help share the load. REFERENCES 1. Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205–211. 2. Dellinger EP, Miller SD, Wertz MJ, Grypma M, Droppert B, Anderson PA. Risk of infection after open fracture of the arm or leg. Arch Surg. 1988;123(11):1320 –1327. 3. Jain AK, Sinha S. Infected nonunion of the long bones. Clin Orthop Relat Res. 2005;431:57– 65.
JHS 䉬 Vol A, November
Evidence-Based Medicine
INFECTED NONUNION OF THE UPPER EXTREMITY
2246
INFECTED NONUNION OF THE UPPER EXTREMITY
Evidence-Based Medicine
4. Forsberg JA, Potter BK, Cierny G, Webb L. Diagnosis and management of chronic infection. J Am Acad Orthop Surg. 2011;19(Suppl 1):S8–S19. 5. Struijs PA, Poolman RW, Bhandari M. Infected nonunion of the long bones. J Orthop Trauma. 2007;21(7):507–511. 6. Brinker MR, O’Connor DP. Nonunions: evaluation and treatment. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma. Philadelphia, PA: WB Saunders; 2009:615–706. 7. Harvey EJ, Agel J, Selznick HS, Chapman JR, Henley MB. Deleterious effect of smoking on healing of open tibia-shaft fractures. Am J Orthop (Belle Mead NJ). 2002;31(9):518 –521. 8. Brinker MR, O Connor DP, Monla YT, Earthman TP. Metabolic and endocrine abnormalities in patients with nonunions. J Hand Surg Am. 2007;21(8):557–570. 9. Adani R, Delcroix L, Innocenti M, et al. Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft. Microsurgery. 2004;24(6):423– 429. 10. Mattar R Jr, Azze RJ, Ferreira MC, Starck R, Canedo AC. Vascularized fibular graft for management of severe osteomyelitis of the upper extremity. Microsurgery. 1994;15(1):22–27. 11. Jupiter JB, Gerhard HJ, Guerrero J, Nunley JA, Levin LS. Treatment of segmental defects of the radius with use of the vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg Am. 1997;79(4):542–550. 12. Dell PC, Sheppard JE. Vascularized bone grafts in the treatment of infected forearm nonunions. J Hand Surg Am. 1984;9(5):653– 658.
13. Saint-Cyr M, Farkas J, Gupta A. Double-barrel free fibula flap for treatment of infected nonunion of both forearm bones. J Reconstr Microsurg. 2008;24(8):583–587. 14. Pinal FD, García-Bernal FD, Regalado J, Ayala H, Cagigal L, Studer A. Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb. J Hand Surg Eur Vol. 2007;32(2):135–142. 15. Ring D, Jupiter JB. Wave plate osteosynthesis in the upper extremity. Tech Hand Up Extrem Surg. 1997;1(3):168 –174. 16. Allende C. Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity. Tech Hand Up Extrem Surg. 2010;14(4):241–247. 17. Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm after trauma: treatment with cement spacer and delayed cancellous bone grafting. J Trauma. 1995;38(6):910 –914. 18. Chen CY, Ueng SW, Shih CH. Staged management of infected humeral nonunion. J Trauma. 1997;43(5):793–798. 19. Pullen C, Manzotti A, Catagni MA, Guerreschi F. Treatment of post-traumatic humeral diaphyseal nonunion with bone loss. J Shoulder Elbow Surg. 2003;12(5):436 – 441. 20. Esser RD. Treatment of a bone defect of the forearm by bone transport. A case report. Clin Orthop Relat Res. 1996;326:221–224. 21. Al-Sayyad MJ. Taylor spatial frame in the treatment of upper extremity conditions. J Pediatr Orthop. 2012;32(2):169 –178.
JHS 䉬 Vol A, November