Advertisement

International Orthopaedics

, Volume 43, Issue 2, pp 417–423 | Cite as

Treatment of infection following intramedullary nailing of tibial shaft fractures—results of the ORS/ISFR expert group survey

  • Cyril MauffreyEmail author
  • David J. Hak
  • Peter Giannoudis
  • Volker Alt
  • Christoph Nau
  • Ingo Marzi
  • Peter Augat
  • JK Oh
  • Johannes Frank
  • Andreas Mavrogenis
  • Xavier Flecher
  • Jean-Noel Argenson
  • Ashok Gavaskar
  • David Rojas
  • Yehia H. Bedeir
  • From the ORS/ISFR expert group on Tibial bone defects
Original Paper

Abstract

Objective

The lack of universally accepted treatment principles and protocols to manage infected intramedullary (IM) nails following tibial fractures continues to challenge us, eliciting a demand for clear guidelines. Our response to this problem was to create an ORS/ISFR taskforce to identify potential solutions and trends based on published evidence and practices globally.

Materials and methods

A questionnaire of reported treatment methods was created based on a published meta-analysis on the topic. Treatment methods were divided in two groups: A (retained nail) and B (nail removed). Experts scored the questionnaire items on a scale of 1–4 twice, before and after revealing the success rates for each stage of infection. Inter- and intra-observer variability analysis among experts’ personal scores and between experts’ scores was performed. An agreement mean and correlation degree between experts’ scores was calculated. Finally, a success rate report between groups was performed.

Results

Experts underestimated success rate of an individual treatment method compared to published data. The mean difference between experts’ scores and published results was + 26.3 ± 46 percentage points. Inter-observer agreement mean was poor (< 0.2) for both rounds. Intra-observer agreement mean across different treatment methods showed a wide variability (18.3 to 64.8%). Experts agree more with published results for nail removal on stage 2 and 3 infections.

Conclusions

Experts’ and published data strongly agree to retain the implant for stage 1 infections. A more aggressive approach (nail removal) favoured for infection stages 2 and 3. However, literature supports both treatment strategies.

Evidence

Clinical Question

Keywords

Tibia infection Intramedullary nailing Nonunion tibia Tibia fractures Treatment algorithm Survey on nonunion 

References

  1. 1.
    Court-Brown CM, Keating JF, McQueen MM (1992) Infection after intramedullary nailing of the tibia. Incidence and protocol for management. J Bone Joint Surg Br 74(5):770–774CrossRefGoogle Scholar
  2. 2.
    Tsang STJ, Mills LA, Frantzias J et al (2016) Exchange nailing for nonunion of diaphyseal fractures of the tibia. Bone Joint J 98(4):534–541CrossRefGoogle Scholar
  3. 3.
    Court-Brown CM (2004) Reamed intramedullary tibial nailing: an overview and analysis of 1106 cases. J Trauma 18(2):96–101Google Scholar
  4. 4.
    Makridis KG, Tosounidis T, Giannoudis PV (2013) Management of infection after intramedullary nailing of long bone fractures: treatment protocols and outcomes. Open Orthop J 14(7):219–226.  https://doi.org/10.2174/1874325001307010219. CrossRefGoogle Scholar
  5. 5.
    Chaudhary MM (2017) Infected nonunion of the tibia. Indian J Orthop 51(3):256–268.  https://doi.org/10.4103/ortho.IJOrtho_199_16 CrossRefGoogle Scholar
  6. 6.
    Calori GM, Philips M, Jeetle S, Tagliabue L, Giannoudis PV (2008) Classification of nonunion: need for a new scoring system? Injury 39(2):S59–S63.  https://doi.org/10.1016/S0020-1383(08)70016-0 CrossRefGoogle Scholar
  7. 7.
    Torbert JT, Joshi M, Moraff A, Matuszewski PE, Holmes A, Pollak AN, O’Toole RV (2015) Current bacterial speciation and antibiotic resistance in deep infections after operative fixation of fractures. J Orthop Trauma 29(1):7–17.  https://doi.org/10.1097/BOT.0000000000000158. CrossRefGoogle Scholar
  8. 8.
    Graves DT, Alblowi J, Paglia DN, O’Connor JP, Lin S (2011) Impact of diabetes on fracture healing. J Exp Clin Med 3(1):3–8.  https://doi.org/10.1016/j.jecm.2010.12.006 CrossRefGoogle Scholar
  9. 9.
    Patel RA, Wilson RF, Patel PA, Palmer RM (2013) The effect of smoking on bone healing: a systematic review. Bone Joint Res 2(6):102–111.  https://doi.org/10.1302/2046-3758.26.2000142. CrossRefGoogle Scholar
  10. 10.
    Chadayammuri V, Herbert B, Hao J et al (2017) Diagnostic accuracy of various modalities relative to open bone biopsy for detection of long bone posttraumatic osteomyelitis. Eur J Orthop Surg Traumatol 27(7):871–875.  https://doi.org/10.1007/s00590-017-1976-y CrossRefGoogle Scholar
  11. 11.
    Schenker ML, Yannascoli S, Baldwin KD, Ahn J, Mehta S, (2012) Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am, (94)12 p. 1057–64. doi: https://doi.org/10.2106/JBJS.K.00582.
  12. 12.
    Kadhim M, Holmes L, Gesheff MG, Conway JD (2017) Treatment options for nonunion with segmental bone defects: systematic review and quantitative evidence synthesis. J Orthop Trauma 31(2):111–119.  https://doi.org/10.1097/BOT.0000000000000700. CrossRefGoogle Scholar
  13. 13.
    Yang Y, et al., (2013) Modified classification and single-stage microsurgical repair of posttraumatic infected massive bone defects in lower extremities. J Recon Microsurg, 29(9) p. 593–600. doi:  https://doi.org/10.1055/s-0033-1348064.
  14. 14.
    Bose D, Kugan R, Stubbs D, McNally M (2015) Management of infected nonunion of the long bones by a multidisciplinary team. Bone Joint J 97(6):814–817.  https://doi.org/10.1302/0301-620X.97B6.33276. CrossRefGoogle Scholar
  15. 15.
    McNally MA, Ferguson JY, Lau ACK, Diefenbeck M, Scarborough M, Ramsden AJ, Atkins BL (2016) Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite. Bone Joint J 98(9):1289–1296.  https://doi.org/10.1302/0301-620X.98B9.38057 CrossRefGoogle Scholar
  16. 16.
    Samuel G, Menon J, Thimmaiah S, et al., (2017) Role of isolated percutaneous autologous platelet concentrate in delayed union of long bones. Eur J Orthop Surg Traumatol. doi.org/10.1007/s00590-017-2077-7.
  17. 17.
    Leighton R, Watson JT, Giannoudis P, Papakostidis C, Harrison A, Steen RG (2017) Healing of fracture nonunions treated with low-intensity pulsed ultrasound (LIPUS): a systematic review and meta-analysis. Injury 48(7):1339–1347.  https://doi.org/10.1016/j.injury.2017.05.016 CrossRefGoogle Scholar
  18. 18.
    Kertzman P, Császár NB, Furia JP, Schmitz C, (2017) Radial extracorporeal shock wave therapy is efficient and safe in the treatment of fracture nonunions of superficial bones: a retrospective case series. J Orthop Res, 12(1) p.164. doi:  https://doi.org/10.1186/s13018-017-0667-z.
  19. 19.
    Metsemakers WJ, Morgenstern M, McNally MA, et al., (2017) Fracture-related infection: a consensus on definition from an international expert group. Injury. doi.org/10.1016/j.injury.2017.08.040.
  20. 20.
    Mioc ML, Prejbeanu R, Deleanu B, Anglitoiu B, Haragus H, Niculescu M, (2018) Extra-articular distal tibia fractures-controversies regarding treatment options. A single-centre prospective comparative study. Int Orthop. 2018 Jan 22. doi:  https://doi.org/10.1007/s00264-018-3775-4.
  21. 21.
    Bao T, Han F, Xu F, Yang Y, Shu X, Chen K, Qi B, Wei S, Yu A (2017) Papineau technique combined with vacuum-assisted closure for open tibial fractures: clinical outcomes at five years. Int Orthop 41(11):2389–2396.  https://doi.org/10.1007/s00264-017-3620-1 CrossRefGoogle Scholar
  22. 22.
    Seng P, Traore M, Lavigne JP, Maulin L, Lagier JC, Thiery JF, Levy PY, Roger PM, Bonnet E, Sotto A, Stein A (2017) Staphylococcus lugdunensis: a neglected pathogen of infections involving fracture-fixation devices. Int Orthop 41(6):1085–1091.  https://doi.org/10.1007/s00264-017-3476-4. CrossRefGoogle Scholar
  23. 23.
    Olesen UK, Pedersen NJ, Eckardt H, Lykke-Meyer L, Bonde CT, Singh UM, McNally M (2017) The cost of infection in severe open tibial fractures treated with a free flap. Int Orthop 41(5):1049–1055.  https://doi.org/10.1007/s00264-016-3337-6. CrossRefGoogle Scholar
  24. 24.
    Romano CL, Romano D, Logoluso N, Drago L (2011) Bone and joint infections in adults: a comprehensive classification proposal. Eur Orthop Traumatol 1(6):207–217CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Cyril Mauffrey
    • 1
    Email author
  • David J. Hak
    • 1
  • Peter Giannoudis
    • 1
  • Volker Alt
    • 1
  • Christoph Nau
    • 1
  • Ingo Marzi
    • 1
  • Peter Augat
    • 1
  • JK Oh
    • 1
  • Johannes Frank
    • 1
  • Andreas Mavrogenis
    • 1
  • Xavier Flecher
    • 1
  • Jean-Noel Argenson
    • 1
  • Ashok Gavaskar
    • 1
  • David Rojas
    • 1
  • Yehia H. Bedeir
    • 1
  • From the ORS/ISFR expert group on Tibial bone defects
  1. 1.Department of OrthopaedicsDenver Health Medical CenterDenverUSA

Personalised recommendations