Clinicoradiological outcomes following single-stage treatment using external fixator, copious bone grafting and high dose antibiotics for infected postosteomyelitic nonunion of femoral shaft

Abstract

We aimed to study clinical and radiological outcomes following a ‘single-stage protocol’ in postosteomyelitic-infected nonunion of the femur in children. The report is based on a retrospective chart review (2010–2018) of 10 children below 12 years of age presenting with nonunion following a pathological fracture after osteomyelitis of hematogenous origin treated with above-mentioned operative modality. All patients were grade A (normal host) on the basis of the physiological classification. Patients with posttraumatic or surgical osteomyelitis were excluded. All patients were treated with a combination of debridement of dead bone and necrotic tissues, acute bone docking, use of external fixator and addition of copious nonvascularized autogenous bone graft obtained from fibula/tibia. The postsurgical period was covered by high dose broad spectrum antibiotics for 6 weeks. At follow up, union, infection, deformity, leg-length discrepancy, motion of hip and knee and ability to perform unaided walking was recorded. Mean age for studied patients (five males and five females) was 6.6 years. Average time elapsed since pathological fracture was 7.7 months (range: 3–15 months). MRSA and MSSA were cultured in three and four patients, respectively. Union occurred in all patients with average time of 3.7 months and total follow up being 2.9 years (range: 1–7 years). There was persistence of deep infection despite union in three patients. Average limb shortening was 4.3 cm (range: 2–7 cm). The knee motion was severely restricted (≤30°) in three patients. According to Paley’s criteria, there were 2 excellent, 4 good, 2 fair and 2 poor results. Single-stage protocol as described above is a usable option for postosteomyelitic femoral nonunions in children. Union occurred in all cases. Healing occurred in three patients despite the persistence of infection. The restriction of range of motion at knee and limb length discrepancy was main complication encountered with this procedure.

Emerged donor limb growth morbidity and malalignment after combined ipsilateral tibial and fibular cortical harvest graft in children. Early follow-up report

“…The combined tibial and fibular harvesting as described in our series, although being a known procedure, has scantly been elucidated in literature [5–7]. Our series on such 16 dual harvests showed that tibial healing proceeded unhindered being an incomplete window-type resection (Fig.…”

“…The combined harvests, however, sum up as a major surgical procedure and require postoperative immobilization in a cast [5]. Postprocedure, the clinician’s focus is largely restricted to primary site outcome [6,7]. The overall impact of harvests on donor legs largely remains undocumented and therefore, formed the basis of the present research.…”

“…When the harvest is obtained with a nonvascularized technique, regeneration of both bones is theoretically possible as the periosteum is preserved. As such, the procedure is commonly perceived to be overall well-tolerated and donor sites are seldom investigated at follow-up [6,7]. Lately, several studies have reported donor site complications both in the short-and long-term after nonvascularized fibular grafts in children [8][9][10][11][12].…”

use of LRS mono-lateral external fixator for the treatment of comminuted femoral fracture with bone loss

“…(2) Application of mono lateral external fixator for femoral bone transport to manage these cases has rarely been assessed in the literature with only seven studies found in the last 10 years with a limited number of cases. (3)(4)(5)(6)(7) This study hypothesizes that managing these injuries by mono lateral external fixator provides good to excellent radiological and functional outcomes.…”