Infected tibia non-union is difficult to treat. I am presenting patient currently undergoing a treatment of infected tibial non-union and non-infected humeral non-union with symptoms going on for 14months. Patient is currently having impressive range of movement in the knee, ankle, shoulder and elbow suggesting excellent compliance with physiotherapy.
Action plan was quite simple: eradicate the infection and fix bot non-union. In the same sitting or preferably in two attempts to let patient recover in-between.
Infected non-union of the tibia was approached first. Bone was debrided, and than put in a "cage" with multiple rings. Defect of bone post debridement was filled with bone substitute loaded with antibiotics.
There are two rings on the proximal tibia, above the non-union, dressing is at the level of incision, where the infected bone was removed, there are two rings in the middle (with additional ring on top to enable connection of struts) and most distal ring with four olive wires to enable future lengthening of the tibia to regain the leg length as soon as the infection is under control. Patient is on iv antibiotics.
Next week we are planning to fix humeral non-union again with fine wire fixatour to enable simultaneous lengthening of the distal humerus whilst the spike of the distal fragment is "being pushed" into proximal fragment medullary canal.
Plan for fixation of the humerus is below. Constructive comments welcome. Questions as well.
17 July 2015
Upper limb fine wire frame completed according to the plan with some minor alterations.
31 July 2015
Correction of upper limb with TSF fine wire frame has been completed and achieved desired position. Today we changed the plan slightly to the fact that we will not push distal fragment into proximal but will maintain position as seen on two X-rays below as this would shorten the limb even more. We are hoping to get away we any additional shortening of the upper limb. And this means that we won't need any lengthening of the upper limb what equals one procedure less..
X-rays of the tibia revealed that fracture of the distal tibia is more or less united and it is safe to proceed with corticotomy and lengthening of the tibia. My estimate that we have to regain at least 10cm of the bone, what means at least 100 days of lengthening every day, providing that everything goes well. And not always does. Reasonable expectation would be in the region of 1/3 increment of the lengthening time what brings us to the time span of 4-5 months of constant lengthening. On the X-rays it looks that the proximal infected non-union site is well opposed and will compress it even further until wires do not bend, as the position is more than acceptable. So far we were lucky, but unfortunately we do expect certain level of complications (pain, pin site infection, wire breakage,...), hopefully not too many.
Plan for next week:
03 August 2015
Today all pin sites were clean, no sign of infection. Also both wounds were clean. Decided that it was safe to continue with lower energy corticotomy of the distal tibia as planned.
Procedure went well, smoothly and good distraction achieved when testing it in theatre.
Why testing under additional distraction?
We always pretension the bone prior to the corticotomy. When corticotomy is completed both bone fragments will spring apart for around 5mm. Not always this is enough to allow distraction of fragments after 7-10 days of consolidation period. If additional distraction test is not performed it can easily happen that the fragments won't move after 7-10 days as the corticotomy was not complete. Learning from my own mistakes.
How is the patient doing post op?
Patient is well, sitting in his bed with some discomfort coming from his ankle and a bit of discharge (blood) coming from the pin sites around the corticotomy. Wound is dressed and compressed with a bandage.
15 September 2015
Since the last publication patient was discharged home from the hospital where he struggled but happy to stay at home.
Pain in his left shoulder is increasing (there is a history of a fall at home) . Plan is to do further imaging to find the reason for it. Otherwise the frame felt stable. X-ray unfortunately does not show any significant new bone formation.
Lengthening of the left leg started almost a month ago. There was a stop for two or more days due to the pain in the ankle. It looks that this resulted in abundant callus formation at the level of the corticotomy. I am slightly worried that it will prematurely heal and new corticotomy will be required. It is still better than non-union but still. Any unnecessary procedure is unnecessary and brings extra risks. With all honesty I did not expect that all this will be plain sailing. Not even close.
Form infection perspective it looks that we have things under control - no clear sinus. Patient is still on iv antibiotics as per Infectious Diseases Consultant advice.
18 September 2015
Further imaging of the left shoulder has been done. No signs of healing. Pins seem stable. All pins sites still dry and clean.
25 September 2015
X-ray of the tibia show impressive callus formation at the level of infected non-union (yellow arrow) but also at the level of callus distraction (blue arrow). The surprising part was that there was no or very little seen on the X-ray from two weeks ago.
Decision was also made how to compress the humerus non-union. Will have to remove the struts and use standard Ilizarov methods to compress the non-union. Hopefully will do it on the Monday coming in Theatres under GA.
29 September 2015
Unfortunately patient was cancelled on Monday due to the lack of time. On the second thought we decided to adjust the TSF frame without anaesthetic if possible. During the preparation we came to the idea to just reposition the shortest strut No 6 and attach it to the additional half ring we just added. Plan is now to re-run prescription with construct as original but ignoring the strut No 6 - this strut will just follow the rest. We are hoping this will work. I certainly do realise that this is not the standard way of using TSF but we do not have enough room for correction with struts and conversion to standard Ilizarov would be extremely tedious and time consuming. Will keep you informed.
Otherwise tibia lengthening is progressing as per plan. Another X-ray check up is due next week.
09 October 2015
TSF prescription for humeral non-union has been done with a few hiccups. As the humerus is not so ap orientated bone as is tibia for example we had to re-decide which tab is the main tab (attachment of struts 1 and 2). X-ray check up is due next week.
Tibia lengthening is progressing as planned. Maybe slightly smaller(thinner, less radio-opaque, blue arrow) regenerate as expected but there still is one. Patient is clinically still doing well with no obvious signs of infection and swelling is in regression (less impingement of the skin onto the frame). Ilizarov type of lengthening for the distal tibia using screws and spanners will be replaced by clickers as there is still a long way to go (as mentioned above). Lengthening is still done in 0.5mm per day (twice per day for 0.25mm) due to the ankle pain. Also quality of the regenerate is suggesting no to go with full speed. New bone formation (callus, yellow arrows) at the level of the infected non-union is building up suggesting non-union is healing.
16 October 2015
One of the wires on the most distal ring (just above the ankle joint) broke and was replaced today by a new one.
We are considering to exchange one of the rings of the tibia frame as the swelling is not coming down as planned. Because the proximal fracture is uniting this should not be to dangerous task for the stability of the construct.
New prescription for the humeral frame has started today and hopefully will manage to compress the fragments together despite the limitation in the space.
03 November 2015
Two rings on the lower leg were exchanged for one bigger ring as planned above. Leg still swollen but the proximal non-union looks like it is healing. Confirmed with the attempt to compress it with the struts but also visible on the X-ray below.
As you can see from the previous X-rays the regenerate is shorter today than previously. This is result of turning clickers into wrong direction. In my experiences this can be only beneficial for the regenerate.
Humerus continues to be a problem. More pain than expected. And proximal pins are leaking - instability? Recent X-rays (below) suggest possibility of a bone bridge, but I would expect that this is just a projection of a callus but no bridging. Another CT scan of the non-union (pseudoarthrosis) at the end of this week.
13 November 2015
CT scan confirmed no healing bone in the humeral non-union (should call it pseudoarthrosis). Humeral frame was removed and revealed stiff fibrous non-union, which was not painful. At the moment we are supporting it with a brace. X-rays are due next week.
With regards to the tibia there was no major problems. Lengthening was slightly interrupted with turning clickers in the wrong direction which in my opinion is beneficial for regenerate. But now we are proceeding with the full speed. Ankle pain diminished a bit. X-rays are below.
30 November 2015
Patient was discharged one week ago but came back today with one broken wire on the distal ring. Broken wire was replaced today with two wires. Short clickers were changed for the intermediate ones. Image intensifier in the theatre showed good callus formation.
Will continue will elevation and lengthening as planed. Another two inches missing in length.
Humeral non-union is getting a bit floppy. Will discus further management in the next week.
05 January 2016
At the last admission we decided not to operate on the humeral non-union. Maybe not the best decision. We continued with tibia lengthening.
On this day patient was re-admitted because of the swelling of the leg. Some discharge from the pin sites but nothing major. Clinical measurement showed that the leg is still about two inches short. Humeral non-union was unstable, mobile.
X-ray of the tibia showed good regenerate but also good callus formation on the proximal non-union site. No obvious signs of loosening around wires.
X-rays of the humerus showed mobile non-union. with some osteolysis in the proximal fragment. Clinically no signs infection on the humerus.
11 January 2016
Humeral non-union fax fixed using Philos plate. I used the same technique as described in Proximal humeral fractures for proximal fragment and then simply attach the distal fragment to the plate. Non-union was taken down as much as it felt comfortable with the radial nerve protected. Bone graft was harvested using RIA from left femur. Good quality bone graft in sufficient volume was impacted into the non-union site behind the plate after medullary canals were opened. No euro-vascular deficit after the procedure. X-rays are below.
CT scan of the tibia was done but unfortunately they scanned the callus distraction site and not the non-union site on the proximal tibia. CT scan shows great regenerate which is nicely circular. Great. But I knew that even before the scan. I will repeat the scan on the proximal tibia. Otherwise the tibia is still around 1 cm short. Will continue with lengthening until next Thursday and hopefully will correct the valgus as well.
20 January 2016
Tibia is almost back to length. Lengthening will continue until Sunday and then stop. Hopefully this will restore the leg length completely.
CT scan has finally been done. Reconstructed images are below. Non-union is still visible but is narrow with areas with full bone bridging. Optimistic.
28 January 2016
Lengthening completed. Ring exchanged for larger diameter. Extra ring added. Patient discharged.
X-ray Before Exchanging of the Ring
X-ray After Exchanging of the Ring (+ one ring added)
22 February 2016
I certainly wasn't expecting that. X-rays are self explanatory.
And the fixation.
02 March 2016
Patient walking with crutches, no major pin site issues. Felt something snapped in his ankle.
Couldn't find any reason or explanation for "snapping". Clinically wires around the ankle stable with no significant discharge from the pin sites. Olive wire which was dented during partial removal of the distal ring is still holding. Quite a surprise to me. Two struts were un-locked (kept unlocking). They were secured by the numbers (TSF).
Due to the wires deformations alignment of the leg is better than previously therefore did not need any further correction. Length is more or less equal on the both sides.
19 April 2016
Leg is quite swollen but does not look infected. Patient is walking with crutches. Left arm still aching occasionally but can use crutches comfortably.
CT scan of the lower leg confirmed progress towards union and good regenerate but not healed yet. X-ray of the left arm is suggesting at least partial union of the non-union and fracture.
03 May 2016
Patient came back earlier as he broke two of olive wires in the distal ring. Expected complication. Otherwise the leg is still the same length with no changes in alignment. Two wires still left on the distal ring and coping with the load. No other issues. Pain under control.
X-ray below confirms that the proximal infected non-union is healing and looks the best as it ever looked. Bone regenerate distally is also improving as expected.
Two broken wires will be replaced by two wires (not three as there is no need), the rest of the treatment will remain the same.
31 May 2016
Another two wires on the most distal ring broke. It was very painful episode according to the patient. Usually wire breakage is not extremely painful, more uncomfortable. Leg is quite swollen.
Shoulder pain is getting stronger. Cannot find any obvious reason on the X-rays but patient is mobilising more and more on his crutches, so shoulder is loaded more and more.
X-ray of the tibia shows some collapse due to the wire breakage but overall alignment is still acceptable.
It is 10 months down the line and treatment is still not finished. Complications are very common and should be dealt with appropriately. Patients should be made aware prior to the start of the treatment that there will be complications and that they do not represent a failure of the treatment.
X-ray of the humerus shows good callus formation, no signs of instability but non-union yet to unite.
07 June 2016
Patient was admitted and swelling came down significantly. Skin still looks cellulite with slightly raised CRP. Walking with weight bearing as tolerated (crutch in the right hand for shorter distances).
Two broken wires were removed and replaced by three new wires. Small adjustment to the overall alignment has been made as well.
05 July 2016
Leg is massively swollen and skin is impinging on the rings. Patient walking on the leg. Pin sites still under control.
X-ray shows further improvement of the regenerate but also some additional drift into varus (measured today as 7 deg varus of the distal tibia).
As the rings are too small again and there is some varus which can be corrected will exchange two middle rings for one and correct the deformity with the TSF.
19 July 2016
Frame has been adjusted. As you can see on the X-rays below two rings were replaced by one. There is residual 6 deg varus mal-alignement which will be correct using TSF frame prescription in next few days.
Patient is comfortable walking weight bearing as tolerated. Discharged home today.
16 September 2016
Patient walking with one crutch. Leg is still swollen. I doesn't look infected.
There was a sudden, very strong pain last week which improved completely. Pain was located at the level of the regenerate.
X-rays today show complete union of the infected non-union without using any bone graft. Regenerate has improved as well, but there is a line on the proximal part of it which I cannot explain. CT scan was requested with a view to remove the frame in the next few months. Some of the reduction has been lost in due corse but will accept it as it is.
28 October 2016
CT scan has been done at is promising. Regenerate is consolidating and the non-union has united. Unfortunately leg was massively swollen and the admission proven to be helpful again in reducing the swelling. No clear sign of active osteomyelitis.
13 January 2017
Patient walking without any support. Comfortable from leg's perspective. Started physiotherapy recently for his shoulder and elbow. Improving slowly.
Pin sites OK. No major discharge.
X-ray showed good maturation of the callus. TSF frame was dynamised today. Patient was booked for removal of the frame in 2 weeks time.
30 January 2017
X-ray confirm healed infected non-union and stable regenerate.
Upper limb function is improving.
Upper limb function is improving.
Follow up in 4 weeks.
28 February 2017
4 weeks since the removal of the frame. No major issues. Swelling coming down. Clinically no sign of infection. Walking without any aid but slight limp.
Treatment for tibia infected non-union completed. Regular follow-ups will follow.
23 May 2017
3 months since the last appointment. No changes. Both bones survived a recent fall which caused a fracture in the non-affected limb.
For the tibia I am sure it is healed but not for the humerus.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.