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Saturday, March 3, 2001

Infected nonunion must be treated aggresively

Infected nonunion of the forearm is a difficult problem which must be treated with aggressive debridement to viable bone with concurrent debridement of avascular scar tissue, say coauthors of scientific exhibit 42.

"This facilitates the eradication of infection and also prepares the wound bed for subsequent bone grafting," they said in a review of their results of using their treatment protocol. "Rigid internal fixation of the bone graft to the recipient area allows for early range of motion, which maximizes functional outcome. Leaving the wound open allows for drainage and prevents the accumulation of fluid, which may inhibit union, and the eradication of infection.

"Although we were not always able to achieve full range of motion, we had achieved union in all our patients with concurrent resolution of infection. We believe that our protocol offers a viable option in the management of infected nonunion of the forearm with excellent chance for union and good functional results.

Their exhibit presents a retrospective review of 14 patients who presented to them with infected nonunion of the forearm. Nine were male and five were female. Both bones were affected in 12 patients and the ulna only in two patients. The mean age of the patients was 45.7 years. Ten fractures were open.

All fractures were initially treated with open reduction and internal fixation. Nine presented with open drainage. Only three had an elevated ESR (>20) and only four with increased WBC count (>9,000). The patients had an average of 5.4 (2-16) procedures prior to presenting to the researchers' institution. Their treatment protocol consisted of:

  1. Initial debridement to bleeding bone and removal of hardware.
  2. Deep cultures taken and intravenous antibiotics begun (triples).
  3. Repeat debridements performed as necessary and culture specific antibiotics.
  4. Return to OR at 7- 10 days for definitive fixation using tricortical iliac crest bone graft and DCP plate.
  5. Early range of motion begun.
  6. Wound left open to heal secondarily; continued soap and water washed until wound closed.
  7. A total of 6 weeks of culture specific intravenous antibiotics given.

All patients ultimately achieved infection-free union of the forearm. The average time period until union was three months (excluding one patient). Thirteen patients achieved infection-free union after their initial treatment. A functional range of motion was obtained in 11 patients (defined as supination 50 degrees and pronation 50 degrees with elbow ROM at least 30-130).

The three patients who fell below our cutoff for functional range of motion had the most previous procedures (average 12 per patient). Complications included one recurrence of infection, one delayed union, one ulnar impingement and three with limited supination/pronation.

"We believe that our protocol offers a viable option in the management of infected nonunion of the forearm with excellent chance for union and good functional results, the coauthors say. They are David R. Miller, MD, Miami, Fla., and Elizabeth Anne Ouellette, MD, department of orthopaedics and rehabilitation, University of Miami, Miami, Fla.

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2001 Academy News March 3 Index B

Last modified 20/February/2001 by IS