[ORT-L] Infected nonunion pilon


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[ORT-L] Infected nonunion pilon

Charles at Blitzer
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Feb 22, 2007, 4:27 PM

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[ORT-L] Infected nonunion pilon	Can't Post

Attached are photo of draining sinus overlying infected tibial pilon.
The CT photos are poor resolution but, I believe, demonstrate poor healing
with poor articular surface.
Culture is Strep viridans.
Pt is 37 yo who fell from his tree stand (hunter) 9/22/06 had 3A open fx.
Underwent debridement & ex fix.
Wound looked excellent and had ORIF 10/2/06 w/ med distal tibial locking
plate as well as ORIF fibula. Developed drainage & underwent I & D hardware
removal, tobra/osteoset pellets, ex fix and 6 weeks abx via PICC line. Wound
looked ok but never completely healed over central portion. I & D 2/5/07 was
no growth & started on VAC. Now has strep viridans and new PICC. His foot is
excellent with no significant swelling or stiffness.
I plan return to OR for extensive debridement of distal tibia. It seems to
me that the entire distal tibia needs to go with hope then returning to do
ankle arthrodesis.
My thought was PMMA spacer block with abx. Then large iliac crest graft with
BMP vs bone transport.
Any thoughts / suggestions are appreciated.

Attachments:

IMAGE_00105.jpg (49.1 KB)

IMAGE_00107.jpg (26.7 KB)

IMAGE_00108.jpg (26.2 KB)

IMAGE_00109.jpg (27.8 KB)

nswolfso at usc
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Feb 22, 2007, 8:06 PM

Post #2 of 3 (4064 views)
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Re: [ORT-L] Infected nonunion pilon [In reply to]	Can't Post

Hello Charles:

It is difficult case and I hope your patient is informed about possibility of amputation. When they recognize BKA is very possible option it is easier to go to the next in its amplitude scenario: tibiotalar fusion. The very last would be the salvage of the ankle joint, which is, in the best case, will give here very stiff joint.

Ironically, I am doing almost similar case tomorrow ( 3B). My only hope patient is infection free. ( see photos attached). I will be doing bone transport plus some other staff;...

Is your patient a smoker?. If so they have to stop right now. I have no doubt smoking significantly affects both soft tissue healing, infection and healing of nonunions. One of my patients was an excellent example of this: when he stops smoking his wound would heal and as soon he starts the drainage and wound opening would take place.

I do not have info on some other important details: PMH, vascular condition, how heavy is this patient, etc. It is important.

Based on the info you presented it seems to me this patient has sequestrum in here nonunion site. You can see it on CT images you have send. You also use a frame which does not give good stability to this site of tibia. I prefer circular frame with small wires distally and half pins in the proximal fragment.

1st stage. I would debride the wound and the site of nonunion and remove the sequestrum. Put antibiotic spacer . It is very important vot to leave this as an open space Use a free flap to cover soft tissue defect. Revise your fixator for a circular small wire, ilizarov type. Apply circular frame incorporating the distal fragment, or, at least talus and calcaneus, eliminating any movement at the site of the ankle joint and non union. IV antibiotics 6 weeks.

( If you are Ilizarov experienced and have no acces to the goog plastic surgeon, which I hope is not a case I can give you some other hints).

2 stage. If no discharge and infection is under control remove the spacer ( make sure plastic surgeon leaves it in, they have tendency to remove it) . Do iether bone transport or, if you are certain, there is no infection - consider bone grafting. Keep fixator on. Do not use plates. It is very reasonable to fuse this ankle . Distal fragment is too short, but...

Once again, tell the patient about the amputation, and NO SMOKING!!!..
Good luck,

Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Clinical Orthopaedics
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
nswolfso@usc.edu
(323) 226-7346 phone
http://www.usc.edu/medicine/orthopaedic_surgery

----- Original Message -----
From: Charles Blitzer <Charles@Blitzer.org>
Date: Thursday, February 22, 2007 4:29 pm
Subject: [ORT-L] Infected nonunion pilon
To: ORT-L@www2.aaos.org

> Attached are photo of draining sinus overlying infected tibial pilon.
> The CT photos are poor resolution but, I believe, demonstrate poor
> healingwith poor articular surface.
> Culture is Strep viridans.
> Pt is 37 yo who fell from his tree stand (hunter) 9/22/06 had 3A
> open fx.
> Underwent debridement & ex fix.
> Wound looked excellent and had ORIF 10/2/06 w/ med distal tibial
> lockingplate as well as ORIF fibula. Developed drainage &
> underwent I & D hardware
> removal, tobra/osteoset pellets, ex fix and 6 weeks abx via PICC
> line. Wound
> looked ok but never completely healed over central portion. I & D
> 2/5/07 was
> no growth & started on VAC. Now has strep viridans and new PICC.
> His foot is
> excellent with no significant swelling or stiffness.
> I plan return to OR for extensive debridement of distal tibia. It
> seems to
> me that the entire distal tibia needs to go with hope then
> returning to do
> ankle arthrodesis.
> My thought was PMMA spacer block with abx. Then large iliac crest
> graft with
> BMP vs bone transport.
> Any thoughts / suggestions are appreciated.
>

Attachments:

Gomez ankle7.bmp (3.32 MB)

Gomez ankle10.bmp (3.29 MB)

nswolfso.vcf (0.35 KB)

wdburman at frontiernet
New User

Feb 22, 2007, 8:35 PM

Post #3 of 3 (4064 views)
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Re: [ORT-L] Infected nonunion pilon [In reply to]	Can't Post

How about this?

J Orthop Trauma. 2006 Feb;20(2):134-7.

Modern papineau technique with vacuum-assisted closure.

Archdeacon MT, Messerschmitt P.

Department of Orthopaedic Surgery, College of Medicine, University of
Cincinnati, Cincinnati, OH 45267-0212, USA.

We describe a contemporary modification of the Papineau technique by
implementing a vacuum-assisted closure (V.A.C.(R)) device in lieu of wet-to-dry
dressing changes. The method makes use of a protocol similar to that
of Papineau
and others for the treatment of chronic osteomyelitis. This protocol includes
aggressive excisional debridement of infected or necrotic bone, open bone
grafting with cancellous autograft, vacuum-assisted wound closure by secondary
intent, and eradication of chronic infection with concomitant parenteral
antibiotics. A representative case report is included to illustrate the
technique.

>Attached are photo of draining sinus overlying infected tibial pilon.
>The CT photos are poor resolution but, I believe, demonstrate poor healing
>with poor articular surface.
>Culture is Strep viridans.
>Pt is 37 yo who fell from his tree stand (hunter) 9/22/06 had 3A open fx.
>Underwent debridement & ex fix.
>Wound looked excellent and had ORIF 10/2/06 w/ med distal tibial locking
>plate as well as ORIF fibula. Developed drainage & underwent I & D hardware
>removal, tobra/osteoset pellets, ex fix and 6 weeks abx via PICC line. Wound
>looked ok but never completely healed over central portion. I & D 2/5/07 was
>no growth & started on VAC. Now has strep viridans and new PICC. His foot is
>excellent with no significant swelling or stiffness.
>I plan return to OR for extensive debridement of distal tibia. It seems to
>me that the entire distal tibia needs to go with hope then returning to do
>ankle arthrodesis.
>My thought was PMMA spacer block with abx. Then large iliac crest graft with
>BMP vs bone transport.
>Any thoughts / suggestions are appreciated.
---
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