• Tratamiento conservador

Todos

• Fijación de tornillo

A1.1

• Reducción cerrada con fijación de tornillo

A1.2, a1.3. a2. a3. C1.3.

• Reducción abierta con fijación de tornillo

A2. C1.3.

• Reducción abierta con fijación de tornillos o suturas

A1.2. a1.3.

• Reducción cerrada con fijación de placa

A2. A.3.

• Reducción cerrada con fijación de clavos

A2. A.3.

• Reducción abierta con fijación de placa

A2. A3. B1.1. B1.3. b1.2. b2. B3. C1.1 c1.2. c1.3. c2.1 c2.2, c2.3. c3

• Reducción abierta limitada con fijación de tornillos

B1.1 y .3. b2. B3. C.1 y .2

• Reducción abierta limitada con fijación de clavos

B1. B2.

• Reducción abierta limitada con fijación de placa

B1. B2. B3. C1.1 y .c1.2

• Hemiartroplastía

B2, B3, C1.3,C2, c3

Introduction

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Introduction
A fracture wound, whether traumatic or surgical, that becomes infected almost always results in
prolonged treatment and a suboptimal outcome.
Any surgeon who treats fractures should be aware of risk factors for infection. Every effort
should be made to reduce the risk of infection by following the basic surgical principles of
fracture care.
For more details see a synopsis of J. Wesley Alexander, MD, ScD; Joseph S. Solomkin, MD;
Michael J. Edwards, MD (2011)Updated Recommendations for Control of Surgical Site
Infections. Annals of Surgery. 253(6):1082-10

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Débridement: definition
The factors that reduce a patient’s ability to resist infection should be corrected whenever
possible.

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All necrotic, and infected, tissue should be removed surgically. The surgical removal of infected
tissue is the mainstay of management of infected fractures. Such surgery is frequently referred
to as débridement. Unfortunately this term, although an official Current Procedural Terminology
(CPT) code of the American Medical Association, is open to interpretation and denotes different
procedures in different surgical contexts and is not clearly defined.
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Débridement, as used in this discussion, means the surgical exposure of the whole pathological
zone and the removal of all necrotic, contaminated, damaged and/or infected tissue, whether
bony or soft-tissue. All loosened hardware should be removed as well.
Principles
Infected wounds should never be closed until all infection is overcome and their condition
permits.
Fractures should be stabilized surgically. Internal fixation devices can compromise local host
resistance, and need to be removed unless they provide absolute stability, and the infection
responds promptly to treatment. If an internal fixation device has to be removed prior to bone
healing, then fracture stabilization by external fixation becomes necessary.

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Bacteriology
Infecting microorganisms should be identified, their antibiotic sensitivities defined, and
appropriate specific antibiotics administered as an adjunct to surgical treatment.
It is now appreciated that not all infecting micro-organisms are free in the wound tissues and
fluids. Those that are free, and therefore likely to be detectable by standard culture techniques,
are called, in modern terminology, planktonic micro-organisms.

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Many of the bacteria that inhabit chronic wounds set up complex polymicrobial biofilm
communities that can only be detected by culture techniques when they happen to detach a
sufficient bolus of planktonic cells that can be grown on conventional culture media.
A major problem in bony infections is the fact that biofilm bacteria cannot be recovered by
standard culture techniques, which means that fracture repairs often yield negative culture
results even when multiple clinical signs point to infection. New techniques such as sonication
can increase the yield of the cultures. It is important to realize culture results are affected if the
patient is being treated with antibiotics at the time of culture.

2Diagnosis of wound infection

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Introduction
Early identification of a wound infection is the first step towards the prompt intensive treatment
necessary for optimal results. Any wound communicating with a fracture, whether due to the
injury, or created by a surgeon, is at risk of becoming infected.
Recognition of those factors that predispose to infection should increase the surgeon’s alertness
to the possibility of infection. Early signs of infection are not specific and may easily be
misinterpreted, as an inflammatory response is normally present in the region of a fracture,
even without infection. Often, the first sign of wound infection is that the inflammation fails to
resolve as quickly as expected. Certainly, increasing signs of inflammation (wound drainage,
redness, swelling, pain and tenderness, fever) must be regarded as indicators of likely infection.
If the surgeon is concerned about infection, all steps to diagnose, or exclude, this possibility
must be taken, as a matter of urgency.
Evaluation of possible infection
The presence of bacteria in an inflammatory wound exudate is proof of infection. Often this is
most readily obtained by sterile aspiration of the wound, or preferably by surgical exploration.
Microscopic examination (Gram’s stain) of the exudate, and appropriate microbiological cultures
may provide evidence of bacterial presence. It has to be borne in mind, however, that there may
be few planktonic bacteria in the wound and that most bacteria may be trapped in biofilms
(see general introduction).
Prior antibiotic treatment may interfere with microbiological studies. Occasionally, increasing
inflammation is evident without recoverable bacteria, but infection must be assumed if the
clinical indicators are strong.
Systemic signs of inflammation, often associated with infection, are provided by several
laboratory studies (see below). By themselves, none of these proves, or excludes, infection. The
diagnosis of such infections is dynamic and based on serial clinical and laboratory observations.
It is the duty of any fracture surgeon to monitor each patient closely for this serious
complication.

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Note: PCR
Rapid advances in the use of molecular detection techniques have recently become available to
clinical laboratories, using real-time polymerase chain reactions (PCR) and appropriately selected
 microarrays. This technology can rapidly identify selected bacteria, based on their DNA, as well
as any antibiotic resistance. Microbiological culture is not necessary to use these techniques. As
examples, it is possible to discover methicillin-resistance of S. aureus within a few hours, as well
as to identify fastidious microbes, and those suppressed by antibiotics. Working with
microbiologists using PCR, surgeons may well improve adjunctive antibiotic treatment, as well as
improve diagnosis and classification of skeletal infections.
Relevant observations include:

 Serial wound examinations under aseptic conditions

 Maximal daily temperature reading
 Full blood count (FBC) with differential white cell count
 Erythrocyte sedimentation rate (ESR)
 C-reactive protein (CRP)
 Bacteriology (gram’s stain, culture and sensitivity)
 Imaging
 Plain x-rays
 (PET) CT scan
 MRI
 Indium111-labelled white blood cell scan
 Technetium 99m labeled phosphate bone scan
Classification of infection
An important guide to treatment is provided by the discipline of classifying an infection according
to several parameters:
 duration of infection
 anatomical location
 host resistance to infection
 infecting organism(s)
 status of fixation
 status of bone healing
 viability of bone and soft tissues
Optimal management of an infected fracture or infected nonunion requires assessment of each
of these factors.

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Clinical examination
Serial observations of clinical symptoms and signs are most important for identifying the
presence of infection. Increasing pain, seepage (either purulent or sero-sanguinous), swelling,
redness, warmth and tenderness all suggest the possibility of a wound infection. Progressive
worsening of one, or more, of these parameters is confirmatory. While some inflammation is
caused by a fracture and by any operation to treat it, its severity should normally progressively
decrease.
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Imaging
X-rays
In the diagnosis of early infections, x-ray imaging plays a negligible role. Radiographic findings
of infection are usually not evident until at least 2 weeks after the onset of infection, even
though bone involvement has already occurred.
Imaging becomes important in the later stages of infection. It is helpful to examine serial x-rays
for progressive changes that could suggest infection.
Radiographic signs are neither sensitive nor specific for infection; e.g., radiographic evidence of
implant loosening may be present as a result of instability, infection, or both.
Ultrasound
Ultrasound is useful to identify any accumulation of fluid (hidden abscess). The method is non-
invasive and may image deeper layers, especially in the thigh. Ultrasound can be helpful for
guiding diagnostic needle aspiration.

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CT
Computed tomography offers a cross-sectional guide for exploration and excision, particularly of
bone fragments(sequestrum).
As with plain radiographs, CT scans offer no specific diagnostic signs for, or against, infection,
and is rarely useful in early infections.

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MRI
MRI offers improved imaging of soft-tissue abnormalities and can show greater anatomical detail
than other imaging methods. Again, MRI signs of infection are non-specific. A disadvantage of
MRI is the problem of artifact related to ferrous metallic implants. Titanium implants produce
less interference.
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Bone scan
Uptake of technetium 99m-labelled phosphate compounds (TCN-MDP) by bone is increased in
areas of higher vascularity, including infections and bone healing. With infection, a 3-phase bone
scan shows increased uptake of labelling in all 3 scan phases.
Absence of uptake suggests impaired vascularity, or bone necrosis. Bone scanning detects
increased bone remodeling that is present around all fractures for 12-24 months. Bone scanning
can not differentiate aseptic hardware loosening from infection. Bone scans are of negligible
value in the early postoperative period of acute fractures.
Indium111-labelled white blood cell scans are more specific for inflammation and infection. The
illustration shows a larger area of uptake, surrounding hyperemia and inflammation with TCN-
MDP (b) than with the indium111 white blood cell technique (a). However, false positives and
false negatives still occur, and such scans can be positive in un-united fractures.

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Bacteriology
If an infected area is to be explored, preoperative aspirate of fluid accumulation and especially
intraoperative tissue sampling from several potentially infected sites, prior to the start of any
antibiotics, provide the best material for detecting the infecting microorganism(s). At least 5
specimens should be taken for microbiology testing. One sample should be sent for
histopathology. Both aerobic and anaerobic cultures should be undertaken. PCR, if available will
speed up, and make more reliable, the characterization of the organisms. If hardware is
removed, this can be cultured as well preferably after sonication.
Histological investigation can reveal a bacterial etiology, even if the microbiological tests are
negative. Superficial wound swabs should be avoided because of low sensitivity and frequent
contamination by surface organisms. Ideally, prior to tissue sampling for culture, it is important
to discontinue any antibiotic therapy for at least a week.

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 Septic arthritis
If the infection is suspected to involve a joint cavity, there is a need for drainage, surgical
clearance and irrigation of that space. At the slightest suspicion of septic arthritis, joint
aspiration should be performed to evaluate the affected joint. If infected fibrinous deposits
(cloudy aspirate) are present, arthroscopic irrigation should be performed repeatedly, every 2-3
days, until the infection resolves. If arthroscopic clearance is unsuccessful, one should proceed
with open synovectomy.
If there is articular cartilage degradation, arthrodesis may become unavoidable.

3Classification of fracture wound infection

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Introduction
A variety of factors can influence the prognosis of fracture wound infections. Unlike
hematogenous osteomyelitis, a fracture wound begins with damaged soft tissue and bone, and
consequent, locally-reduced resistance to infection. There may also be necrotic bone, and
perhaps foreign material, where bacteria are protected from host defenses and blood-borne
antibiotics, often sheltering in biofilms (seegeneral introduction).
Factors to consider in categorizing infections are:
 duration of infection
 anatomical area of bony involvement
 host resistance (systemic and/or local)
 status of fracture fixation
 status of fracture healing
 microbiology
Classification according to chronology of onset of infection
The time of onset of fracture-site infection is relevant, since progressive infection leads to
additional tissue damage and spread of infection outwards from the original infected locus. The
diagnosis of infection within 2 weeks of injury or the first open intervention is to be regarded as
an early infection. Diagnosis after two weeks may suggest that the infection was dormant for a
period before declaring itself. The diagnosis of late infection generally implicates more extensive
tissue pathology than if picked up earlier.

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Early presentation of infection
 Infection, diagnosed in the first two weeks after injury or after the first surgical intervention, is
likely to have caused less further tissue damage, than if discovered later.
The treatment of all fracture wound infections is urgent and is primarily surgical, with antibiotics
as an adjunct.
There is no place for the administration of antibiotics and a “wait and see” approach.
Click here to read more about early presentation of infection.

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Later presentation of infection
Infection may not be seen until several weeks after surgery.
More extensive and intensive treatment is usually necessary.
Click here to read more about delayed presentation of infection.

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Chronic fracture wound infection
Late presentation, chronic infection is associated with extensive infection of tissues and dead
bone, sometimes sequestered.
Treatment relies on
 total surgical removal of all dead and infected tissue, including bone
 removal of implants
 restabilisation of the fracture, using external fixation
 appropriate adjunctive antibiotic therapy
Click here to read more about chronic fracture site infection.

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Recurrent osteomyelitis
Posttraumatic osteomyelitis may recur, sometimes years after the original infection appeared to
have resolved.
Treatment depends on
 fracture healing
 implants
 sequestra
Treatment relies on
 Surgical removal of all infected and dead tissue
 Identification of the responsible microorganism from cultures of biopsies
 Fracture stabilization, as necessary, with external fixation
 The use of appropriate adjunctive antibiotics
 Soft-tissue reconstruction, once infection is eradicated
Click here to read more about recurrent osteomyelitis.

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Cierny’s classifications
Cierny has classified fracture site infections according to a number of criteria:
 anatomical
 host resistance
 microbiology and
 status of fracture healing.
These are all important factors to be taken into consideration.
Click here to read more about Cierny’s classifications.

4Treatment - initial surgery for fracture wound infection

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Introduction
If an infection is strongly suspected, the surgeon must proceed urgently to exploration of the
wound, obtaining tissue for culture, and removing all non-viable tissue and exudates.
Such débridement (see below) involves the surgical excision of all necrotic and/or infected tissue
from the wound.
Débridement must include:
 Wide exposure of the whole pathological zone
 All exudate (hematoma and pus)
 The abscess membrane
 Sinus tracks
 Granulation tissue
 Unhealthy wound margins
 All dead bone
 Loosened hardware
Look carefully for dead bone and any remaining foreign material. Preserve nerves, identifiable
blood vessels and viable tendons.

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Débridement
The surgical excision must be complete and thorough.
Adequate, timely débridement is the most important element of the treatment of a fracture-
wound infection.
With well-established infections, there may not be a clear demarcation between viable and non-
viable tissue. Radical excision may be necessary to eliminate infection, even though it may
increase the complexity of reconstruction.

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After débridement, the surgical site should be thoroughly irrigated with Ringer-lactate solution to
reduce the bacterial population. The use of pulsatile lavage has been questioned as the water jet
might transport bacteria deeper into the soft tissue. In cases with large amounts of dead tissue,
or grossly purulent wounds, repeated surgical clearances are indicated. Deciding what tissue to
remove and what tissue to retain is the essential challenge of débridement. Such decision-
making is learned from experienced surgeons and by practice. Common errors are failure to
remove enough compromised tissue, and/or to do so in a way that injures the retained tissue.
An organized approach that proceeds in orderly steps through tissue levels is required. Any non-
viable skin is excised. The incision should be extended, as necessary, for adequate exposure of
the whole infected zone. The depths of the wound are then exposed, and must include all of the
previous surgical exposure. Any extension of hematoma, pus, or necrotic tissue, should be
explored fully.
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With acute wound infections, internal fixation devices may be retained, if they continue to
provide absolute mechanical stability. If the implants are loose, and in more established
infections, it is advisable to remove all hardware and to restabilize with an external fixator. Make
sure to position the pins far enough from the infected wounds, while still maintaining adequate
stability.

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Excise the surface of the exposed tissue to leave clearly viable margins of subcutaneous tissue,
fascia and muscle. Non-viable bone must also be removed with a high-speed burr (suitably
irrigated to cool the tissue), or preferably osteotomes, until bone bleeding is encountered. Small
bleeding osseous vessels (“paprika sign”) indicate viable bone.
Copious irrigation with Ringer-lactate solution helps to remove bacteria, bits of dead tissue and
blood clot, and improves the surgeon’s ability to examine the wound.

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A “second look” and possibly further débridement should be undertaken, until the wound surface
is completely viable. Staged surgical clearance is illustrated.
Local débridement of an infected nonunion
a) The nonunion is covered by granulation tissue, stained with methylene blue, previously
injected into the sinus.
b) After excision of the granulation tissue, the necrotic bone adjacent to the nonunion contrasts
directly with the vital bone.
c) After complete surgical clearance, only vital bleeding bone and soft tissue is seen.

5Treatment - management of the fracture wound

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Initial antibiotic treatment
Before starting therapeutic antibiotics, it is important to obtain adequate cultures, or PCR
characterization (if available). At least 5 samples should be obtained in the operating room from
different locations in the wound. Only if the patient has evidence of septicemia should antibiotics
be given before wound exploration.
Selection of antibiotics for initial treatment is based on the antibiotic sensitivities of likely
infecting organisms, including any results of previously positive cultures.
Generally, broad-spectrum, intravenous antibiotics are advisable as soon as cultures have been
obtained. Initial antibiotics are selected, based on the results of gram’s stain, and on institutional
frequency statistics (see table on left; Trampuz A, Zimmerli W (2006) Diagnosis and treatment
of infections associated with fracture-fixation devices.Injury.37 Suppl 2:S59-66.).
Methicillin-sensitive S. aureus (MSSA) is still the most likely infecting organism in most areas.
Institutionalized patients have a higher risk of methicillin-resistant S. aureus (MRSA), in which
cases vancomycin may be advisable.
Coverage with antibiotics active against gram-negative microorganisms is wise for hospital-
acquired infections.
All of the above should be considered provisional treatment until culture results become
available.

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Definitive antibiotic treatment
Once culture results and sensitivities are known, choose the optimal antibiotic for the infection,
in consultation with an infectious-disease specialist. Remember that antibiotics are but an
adjunct to adequate surgical clearance, and recognize that an infection that does not respond
will need repeat surgical exploration and clearance.
If laboratory services are limited, then the choice of antibiotics is determined by the most
appropriate available for the most likely organisms.
Prolonged intravenous antibiotics (e.g., six weeks), the use of combinations of drugs, and
continued oral medication after initial intravenous therapy may be necessary.

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Dead space within the wound
After the first surgical clearance of an infected fracture wound, it is essential to defer suture
closure or other definitive soft-tissue cover. Closure may be considered when final clearance has
resulted in resolution of the infection.
Empty space (“dead space”) under tissue flaps, or within bony cavities, within the excised wound
allows further accumulation of exudate and is likely to become a reservoir of bacteria. Antibiotic
levels will be low in this poorly-perfused accumulation of fluid.

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Filling this dead space is an important part of wound management. Alternative treatment
strategies include the use of antibiotic beads, or other temporary space fillers (calcium sulphate,
bone cement, etc.). The wound itself should be covered to avoid desiccation, or secondary
contamination. This can be done with an impermeable dressing (adherent plastic), or with
vacuum-assisted closure, as illustrated. The latter, by applying suction, reduces dead space
volume in pliable tissues.

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Dead space in bone
A significant bone defect may be filled with antibiotic beads, or other space filler.
Recently, the technique of Masquelet has become popular. This involves the insertion into the
bony defect of a solid antibiotic-containing cement spacer, which is left in place for 6-8 weeks
while a membrane develops around it. The spacer is then removed and the surrounding
membrane is filled with autologous bone graft. (The membrane has been studied extensively
and it has been suggested that this membrane has osteogenic capacity.) This often consolidates
when used for small to medium-size defects.
For more details see: Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou
R(2011) Masquelet technique for the treatment of bone defects: tips-tricks and future
directions. Injury 42(6):591-8. Case taken from article with permission from Elsevier.

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Antibiotic cement plug in place. Make sure the cement fills the defect and also covers a few
mmm of the cortex on either side of the plug. The cement can be prepared with addition of heat-
stable antibiotics of choice.

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Membrane incised 6 weeks later

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Membrane retracted, cavity healthy for bone grafting

6Treatment - implant retention or removal

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Implant retention or removal: plates and screws
For as long as a plate and screws provide absolute stability, fracture healing can usually take
place despite the presence of treated infection, notwithstanding the presence of a metallic
 foreign body. It appears that in most cases, stability is more important than the negative effects
of the foreign body upon host defense.

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Typically, fixation remains stable in early infections. However, at whatever stage, if the implants
are loose, they must be removed. External fixation stabilizes the fracture while avoiding a
metallic foreign body in the infected fracture wound, and is the best choice for early fracture
destabilization in the presence of infection.

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Stabilization with external fixation
The diagram demonstrates an ideal external fixation placement. The pins do not hamper surgical
access to the infected zone, and are well-separated within each fragment, so as to provide
optimal stability. Two bars also improve the strength of the fixation. The configuration should be
planned carefully.
An external fixator can be used either as a temporary, or as a definitive, stabilizer. Even if
definitive external fixation is planned, a temporary fixator may be best after initial débridement.
This aids repeated clearance and wound care. Once further wound access is no longer required,
a new fixator that provides optimal stability can be applied.

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Mistakes in pin insertion for external fixation are:
 Drilling at excessive speeds or with a blunt drill bit (A), producing thermal necrosis of bone.
 Insertion of the Schanz screws, or pins, without adequate pre-drilling (B) causing microfractures,
as well as excessive heat, which results in small necrotic bone fragments, or ring sequestra.
 Correct pre-drilling and correct pin/screw insertion (C) minimize the risk of pin-track infection.
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Plates and screws
If an identified infection is treated early, and its fixation remains stable, then with appropriate
surgical clearance and antibiotics, the infection is likely to respond and to remain suppressed
during fracture healing. Despite successful fracture healing, later recurrent infection can lead to
the need for hardware removal.
After the “infected hardware” is removed from the united fracture, and any necessary further
excision of questionable tissue and/or bone has been undertaken, the infection usually resolves
satisfactorily with a low risk of recurrence.
The pictures to the left: Plated tibial fracture. Early infection debrided. Plate absolutely stable
and left in situ. Eventual granulation over bone and then partial thickness skin grafting.

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Implant retention or removal: IM nails
If a fracture wound infection develops after intramedullary nailing, it is likely that the infection
has spread along the medullary cavity. The infection may be early, or late, before or after union.
Adequate surgical clearance requires removal of the nail and reaming of the medullary canal.

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During initial clearance, a distal opening is created at the lower end of the nail track, in order to
allow debris from reaming to escape, and to drain the “sump”. The canal is then reamed to a
diameter 1.5 mm larger than the removed nail, and is thoroughly and copiously washed out with
Ringer-lactate solution. If there are obvious cortical sequestra, these need removal by open
procedure.
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An external fixator should be applied for stability, if the fracture is not healed.
If the infection is early and due to a less virulent bacterium, then renailing might be considered.

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If the infection is late, or due to resistant organisms, external fixation is preferable to renailing.
An alternative is to insert temporarily a reinforced, antibiotic-containing polymethylmethacrylate
(PMMA) “nail” into the medullary canal, after reaming out the infective membrane and thorough
lavage of the IM canal, also excising any sinus track and any sequestra. An antibiotic-loaded
PMMA nail is prepared by injecting liquid bone cement, pre-mixed with antibiotics (e.g.
tobramycin 1 g per cement batch) into both ends of an appropriately sized chest tube which is
vented in the middle to allow complete filling. A small-diameter flexible rod (e.g., nailing guide
wire) is inserted before the cement hardens. The chest tube is then cut off.
The “nail” can be left in situ until the fracture has healed, or until the infection is under control,
and then replaced with a solid metallic nail – a solid nail is used in order to avoid the hollow
nail’s becoming a hiding place for bacteria.
Implant retention or removal: external fixators
Since external fixator pins are usually distant from the fracture wound, their removal is rarely
required, but adjustment, or reinforcement, of the frame may be required to ensure alignment
and stability.
Should an external fixator pin track become infected, the pin should be removed, the pin site
surgically cleared, and a new fixation pin placed into healthy bone. The pin track clearance is
best achieved with a hand drill and a bit slightly larger than the residual pin hole, together with
copious irrigation. If it is anticipated that external fixator will be in place for longer (2-3 months)
one can consider the use of hydroxy apatite coated pins. They have been shown to be less prone
to loosen.

7Treatment - wound closure and definitive stabilization

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Wound closure
Following infection after ORIF (A, B) and after débridement has been satisfactorily completed, in
one or more procedures (C), consideration must be given to choosing the best means of wound
closure. Suture closure, particularly with skin tension, carries very high risks of wound healing
problems. If possible, delayed primary suture closure can be considered. If this is chosen,
however, the surgeon must watch carefully for wound breakdown, or recurrent infection.

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A safer alternative is to leave the wound open and allow it to heal by second intention (D), or
with the use of split-thickness skin grafts. This is appropriate for wounds without exposed
hardware, bone, cartilage, or other sensitive tissues.

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If the wound is widely open, or tissue protection is necessary, some form of flap coverage will
probably be necessary. Vacuum-assisted wound closure can be used to reduce the size of an
open wound and to promote granulation tissue. A clean granulating wound with a healthy viable
base may be covered with a split-thickness skin graft. An alternative temporary dressing for an
open wound is an impermeable adhesive drape to create a space (bead pouch) for antibiotic
beads.
Closure with local, or free, flaps is often appropriate for larger and more complicated wounds,
once the infection has been adequately cleared surgically.
It is important to close a complex wound as soon as is safe, rather than leave it open too long
and risk secondary infection. The timing of these stages requires mature surgical judgment.
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Fill dead space
Antibiotic beads
Surgical débridement of unhealthy soft tissue and/or bone may leave dead space between bone
ends, or under flaps.
When the excised infected wound presents “dead space”, antibiotic-laden cement is frequently
used, both to fill the space and to deliver locally high doses of antibiotic. A common technique is
the use of antibiotic-laden polymethylmethacrylate (PMMA) beads.

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Antibiotic-impregnated beads may be purchased in some countries (at some expense), or made
by the surgeon more cheaply. One gram of cefazolin (a first generation cephalosporin), or 1.2 g.
of Tobramycin is mixed with each standard package of PMMA and, as it hardens, beads of 5 mm
are carefully wrapped around a non-absorbable heavy nylon stitch (see adjacent photograph),
knotted at intervals to prevent sliding of the “beads”.

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Definitive stabilization
The anatomical classification ( see Cierny classification) of adult bone infection helps to
determine the method of definitive stabilization when the fracture has not united.
Medullary osteomyelitis (type I) is usually associated with an intramedullary nail, which
may, or may not, have been removed during initial surgery for infection. Once the tissue is
healthy, the bacteria are sensitive, and the patient is systemically healthy, it may be appropriate
to restabilize the fracture with another nail.
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Superficial osteomyelitis (type II) is typical of a healed fracture with superficial bone
necrosis, often deep to a plate. After removal of the plate, this superficial necrotic bone is
removed with a burr, or a chisel, until underlying bleeding bone is reached. Replacement fixation
is only needed if fracture healing is tenuous.
Wound coverage (closure, or partial thickness skin grafting) may follow soon after such
superficial surgical excision, once resolution of the infection is assured.

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Localized, full-thickness osteomyelitis (type III) may be associated with a ununited
fracture. Surgical excision back to bleeding bone may remove so much cortex that the structural
integrity of the bone is compromised and pathological fracture is a risk. Mechanical protection
will then be necessary, using an external fixator. More complex options for soft-tissue closure
(local or free flaps) may be required.
Bone grafting is often necessary, but should be delayed until soft-tissue coverage is healed and
stable, and the infection has healed.

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Diffuse osteomyelitis (type IV) causes widespread areas of infected and/or necrotic bone, so
that extensive surgical clearance is necessary. This may result in a segmental defect. Such
defects will require bone grafting, bone transport, or fixing in a shortened position if loss of
length is acceptable.
Wounds associated with type IV posttraumatic osteomyelitis often need complex soft-tissue flaps
for closure. Such widespread infection may justify amputation, especially in under-resourced
healthcare environments.

8Treatment - bone and soft-tissue reconstruction

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Principles
After eradication of infection by surgery, combined with appropriate antibiotics, and the creation
of a viable and stable soft-tissue environment, skeletal reconstruction comes next.
During the program to eradicate the infection, bear in mind the likely reconstructive options
(bone graft, bone transport, or amputation), planning carefully incision placement and external
fixator pin locations, etc., provided this does not compromise infection control.
Stabilization
Skeletal stability facilitates
1. fracture healing
2. enhanced wound care
3. final reconstructive surgery (soft tissue and bony)
4. functional aftercare

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External fixation
In surgery for bone infection, external fixation may need to remain in situ for long periods. It
may be necessary to replace one, or more, pins during the course of treatment.
There are 3 basic systems:
1. external fixation with Schanz pins and tubular frames
2. ring fixators anchored with tensioned wires
3. hybrid ring fixators (using both tensioned wires and Schanz pins)
All three systems have advantages and disadvantages. The ring fixator frame is much more
difficult to install, but can be used for compression and lengthening. They are also quite
uncomfortable for the patient when ambulating. Hybrid frames are simpler and tensioned wires
may have fewer pin-related problems, while external fixation with Schanz pins is the simplest
and is very adaptable.
These frames must provide stability, just as in any other fracture fixation situation. If instability
occurs (loosening, or infection) then they must be replaced.
Internal fixation with plates and nails
Plates and nails involve implantation into the site of the treated infection. They are rarely used in
any previously infected wound as this increases the risk of infection recurrence.
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Bony reconstruction
Eradication of infection, restoration of stability, and soft-tissue closure should be achieved before
limb reconstruction.
At this stage, bone grafting, or bone transport, is performed, as needed, to achieve union,
and/or to reconstruct a defect.
Initially, it may be helpful to accept some limb shortening to achieve wound closure, stability,
and/or fracture healing. If the shortening is excessive, or if it involves angulation, these can be
corrected with distraction histogenesis (Ilizarov technique), as a final stage of reconstruction.

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Bone graft options
Autogenous cancellous bone graft, harvested from any standard donor site is the material of
choice for promoting union and filling smaller defects.
For treating tibial fractures, posterolateral, or central placement, adjacent to healthy muscle,
may avoid the infected focus. For the humerus, femur, or forearm, the best position of the graft
depends on the defect, the soft-tissue envelope and the fixation.
Bone defects remaining after resection of dead, or infected, bone are challenging to treat. The
longer the defect, the more difficult the treatment.
Circumferential defects of 1-6 cm in long bones usually heal if filled with autogenous bone graft,
and stabilized appropriately. Defects greater than this usually need distraction histogenesis, or
free vascularized bone transfer.

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Open cancellous bone grafting (Papineau technique), leaving the graft exposed beneath a
nonadherent dressing, is a well-tried technique for reconstructing defects. It is best used for
strengthening partial segmental defects. It can achieve bony bridging and secondary soft-tissue
coverage concurrently, since granulation tissue should form over the graft and under the moist
dressing. A split-thickness skin graft can then be applied.
Some of the superficial bone graft is inevitably lost and will have to be removed before
granulation occurs. This technique has a fairly high reported success rate.
A more modern adaptation is to use a vacuum-assisted closure system over cancellous bone
graft.

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This case shows an infected subtalar fusion treated by Papineau technique, using vacuum
assisted closure.
The case illustrations are taken from Archdeacon MT, Messerschmitt P (2006) Modern
Papineau technique with vacuum-assisted closure. J Orthop Trauma; 20(2):134-7.

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Bone transport with distraction osteogenesis
Slow distraction of an osteotomy with stable (usually external) fixation creates new bone.
Distraction rate is usually limited to 1 mm per day.
Click here for more background on Ilizarov’s techniques.

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Soft-tissue reconstruction
Soft-tissue coverage
As a rule, soft-tissue coverage without complete surgical clearance of the underlying infection is
useless.
A further rule is that wound closure under tension will always fail. The wound edges will necrose,
the wound opens and secondary infection is unavoidable.

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Direct suture closure is rarely possible, or desirable. Consider split-thickness skin grafts,
rotational muscle flaps, fascio-cutaneous flaps, or free vascularized flaps.

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Negative pressure dressings (vacuum-assisted closure) are very useful over some open wounds,
or open soft-tissue defects. As expecience with these vacuum-assisted approaches is increasing,
it seems that prolonged vacuum assisted closure (> 10 days) should be avoided.

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Split-thickness skin grafting and secondary wound healing
If an open wound involves loss of skin and subcutaneous tissue, but has a base of healthy
muscle, fascia, or tendon sheath, granulation tissue will form on the base and a split-thickness
skin graft (STSG) can be applied, or the wound can be allowed to heal in from its sides (second
intention).
Bare bone (without periosteum), exposed blood vessels, nerves and tendons (without
paratenon) are all harmed by desiccation and do not support granulation tissue and STSG. These
tissues should never be left exposed, and should be kept moist with appropriate dressings.
Alternative coverage techniques should be used. Definitive coverage should be achieved as soon
as possible.
The “reconstructive ladder” shown on the left presents in increasing order of complexity the
options available for wound closure, and is helpful for treatment planning.
Other than STSG and some local rotation flaps, the more complex soft-tissue reconstructions
should be undertaken by surgeons experienced in these techniques, e.g., plastic surgeons.

9Treatment - amputation

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Amputation for osteomyelitis
It is rare for systemic infection to flare out of control in patients with chronic osteomyelitis. For
such patients, amputation is almost never an urgent, life-or-death decision. However, should
repeated attempts to control infection, secure bone healing and restore function be unsuccessful,
amputation may prove to be the best way to restore function and help the patient to resume a
more normal life.

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The informed decision to amputate should be considered carefully and individually, including
both the patient and family.
The surgeon’s job is to inform the patient about realistic expectations.
Different cultures, countries and religions bring different perspectives to this controversy. In
many parts of the world, simple inexpensive but useful prosthesis can be made locally.
This illustration shows a basic below knee prosthesis from Africa and the celebrated Jaipur foot
from India, each made locally.
If the patient makes the informed decision to proceed to amputation, the surgeon should plan
the most functional level of amputation proximal to the diseased tissue. Consultation with a
prosthetist may be helpful. The patient may wish to discuss amputation with another person who
has undergone this procedure at a similar level.
The patient should attain optimal possible nutritional and physiological condition, with
suppression of active infection by antibiotics, further surgical clearance, or even a preliminary
amputation just above the infected zone.
Once all of the infected tissue has been amputated, continued infection treatment is no longer
required.

Syndrome compartimental

Introduction

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Principles
Compartment syndrome is a true surgical emergency. Failure to diagnose it and to institute
urgent treatment by decompression usually results in major limb disability.
In compartment syndrome increasing tissue pressure prevents capillary blood flow and produces
ischemia in muscle and nerve tissue. The process is progressive and leads to necrosis with
permanent loss of function.

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Treatment of compartment syndrome requires surgical release of the closed osteo-fascial

compartment by wide and lengthy division of the skin and fascial envelope.
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Incidence
Muscle compartment syndrome is a relatively common occurrence in the osteofascial
compartments of the lower leg. It also may occur in other anatomical compartments. Other
common sites are the forearm, thigh, foot and hand. Forearm compartment syndrome may also
be associated with supracondylar humeral fractures in children. Muscular young adult males are
at particular risk.
A metanalysis of tibial shaft fractures has revealed that the overall risk of compartment
syndrome following these injuries varied across studies from 2.7%–15.6% ( Midshaft tibial
fractures: Risk of compartment syndrome, OTD 2010; 03).

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Causes
Muscle compartment syndrome occurs most commonly after high-energy limb injuries. However,
it can occur after apparently trivial injuries, with or without fractures, or elective extremity
surgery. Crushing injuries are at high risk of compartment syndrome. Certain other insults, such
as burns, or prolonged compression (as may occur in a comatose, unprotected patient), may
also cause muscle swelling and precipitate the syndrome.
A further cause can be edema from abnormal capillary permeability caused by reperfusion after
prolonged ischemia. Tight bandages, splints, or casts can also elevate compartmental pressure
and contribute to development of compartment syndrome.

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Pathophysiology
Compartment syndrome occurs when the pressure within a closed osteo-fascial muscle
compartment rises above a critical level. This critical level is that tissue pressure which collapses
 the capillary bed and prevents low-pressure blood flow through the capillaries and into the
venous drainage. Normal tissue pressure is 0-10 mm Hg. The capillary filling pressure is
essentially diastolic arterial pressure. When tissue pressure approaches the diastolic pressure,
capillary blood flow ceases. A number of studies have shown that
 if diastolic arterial pressure is less than 30 mm Hg above tissue pressure, compartmental
capillary blood flow is significantly obstructed and severe hypoxia occurs in muscle and nerve
tissue.
The critical measurement is muscle perfusion pressure (MPP), the difference between diastolic
blood pressure (dBP) and measured intramuscular tissue pressure. (MPP has also been called
ΔP, to indicate the difference between diastolic blood pressure and intramuscular pressure.) This
difference in pressure reflects tissue perfusion far more reliably than the absolute intramuscular
pressure.
Muscle tolerates short periods of hypoxia, but after a few hours, progressive necrosis begins.
An arterial injury may cause compartmental tissue ischemia. After blood flow is restored,
capillaries leak and ischemic muscle swells. Reperfusion injury is another cause of compartment
syndrome.
2Diagnosis

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Symptoms
The diagnosis of this severe complication rests on two factors: a high index of suspicion and a
thorough understanding of its variable clinical presentation.
In a conscious and alert patient, there will be unrelenting, worsening pain, greater than
expected for the particular injury, and not related to limb position.
Commonly there is a relatively pain-free interval, perhaps a few hours following fracture
treatment, before such pain develops.
The level of pain can often be judged by increasing requests for ever-stronger analgesia, or
increasing use of patient-controlled analgesia (PCA) systems. Any nerve traversing the involved
compartment will become hypoxic, often causing numbness and tingling in the nerve
distribution. After some hours, ischemic nerves cease to function and the pain resolves.

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Signs
Clinical signs of an impending muscle compartment syndrome include tenderness and induration
of the affected compartment, increase in the pain on passive muscle stretching, possible sensory
(and later motor) deficit in the territory of a nerve traversing the compartment and muscle
weakness.
The presence of a distal pulse does not exclude compartment syndrome, because in a
normotensive patient the muscle pressure rarely exceeds the systolic level.
In an unconscious, drugged, or intoxicated patient, it is easy to miss a compartment syndrome.
Any visible limb swelling becomes a vital clue as does persistent, unexplained tachycardia. For
such patients, direct tissue pressure measurement is very helpful for diagnosis.

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Investigation
Intracompartmental pressure measurement
When compartment syndrome is obvious, there is usually no benefit from measuring pressures
and immediate fasciotomy can be undertaken.
When the diagnosis is unclear, or possibly absent, compartment pressure measurement may be
confirmatory, or prevent unnecessary fasciotomy. Various techniques are now available to
measure the intracompartmental tissue pressure.
All trauma surgeons should adopt a technique that is available for them and their teams. This
might involve use of a commercially available compartmental pressure device, a mercury
manometer, large-bore needle and connecting tubing (after Whitesides), or an electronic strain
gauge used for physiologic monitoring in ICU, or the OR.
If the necessary equipment is not available for direct pressure measurement within the muscle
compartment, then the diagnosis must be assumed if there is a reasonable clinical suspicion.
3Treatment

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Timing
In established muscle compartment syndrome, the hypoxic muscle will become necrotic within
hours. It is generally accepted that after 6-8 hours of inadequate muscle perfusion pressure
(MPP), extensive muscle necrosis is likely and effective release of the muscle compartments
involved is unlikely to avoid severe muscle contracture. Similarly any peripheral nerve passing
through the compartment is likely to suffer permanent functional impairment.
It is therefore of paramount importance that the compartment hypertension be released as an
emergency intervention.
If diagnosed within 8 hours
The only appropriate treatment is dermato-fasciotomy of all involved compartments.
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Late diagnosis
There is some limited evidence in the published literature to suggest that in delayed cases,
where there is already extensive muscle death, dermato-fasciotomy has a high risk of infection
of the dead tissue, septicaemia and, in some cases, death. There appears to be a high
amputation rate in such cases (Finkelstein JA, Hunter GA, Hu RW. (1996) Lower limb
compartment syndrome: course after delayed fasciotomy. J Trauma. Mar;40(3):342-4.)
Where recognition of an established compartment syndrome is delayed for more than 8-10 hours
after probable onset, the decision to perform a dermato-fasciotomy requires judgment by the
most experienced surgeon available. This situation is common after mass disasters (e.g.
earthquake). Exposure of partially necrotic muscle produces a wound with high risk of infection.
Fracture fixation
If fracture stability is important for adequate care of the injured limb, particularly if a
compartment syndrome has damaged the local muscles, this can be provided temporarily by
external fixation, with minimal additional surgical trauma. Alternatively, internal fixation with an
intramedullary nail, or a plate, can be undertaken to achieve immediate definitive stabilization, if
appropriate. After stabilization, the fasciotomy wounds are left open, as discussed next.

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Aftercare
Delayed surgical closure
Once any skeletal injury is under control, the fasciotomy wound(s) healthy and the swelling of
the soft tissues has sufficiently regressed, consideration must be given to achieving skin
coverage.
The simplest and safest technique is to cover the healthy soft-tissue defect with a split skin
graft. At a later date, when the limb contours have returned to normal, the grafted area can be
excised and secondary skin closure performed without tension.
It is tempting to the surgeon to try early secondary skin suture, rather than skin-graft coverage,
once the swelling has subsided. This is only permissible if it can be achieved without any skin
tension; it is inadvisable in smokers, who have impaired capacity for soft-tissue healing.
Fasciotomy wounds tend to contract and become difficult to close. Careful use of elastic
retention sutures (elastic vessel loop woven through skin staples) can help to counteract skin
contraction, and be tightened progressively as swelling resolves. This can help to reduce the size
of the defect to be covered.
Postoperative splintage
It is important to splint the limb in a neutral, or functional, position, particularly if any muscle
damage has occurred and contractures could therefore develop.