Peter_Trafton at brown
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Jan 13, 2009, 8:36 PM
Post #27 of 27
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RE: [ORT-L] tibia infection after IMN
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Hi Marek,
Re dead bone - I meant entirely dead, circumferentially, around the contacting bone ends.
Still skeptical about MRI "proof" of pathophysiology, I would submit that this patient's new fracture site is significantly through callus, which has proven its viability. So I was being pedantic, while admitting another possible reason for surgery, and not trying to suggest that there was a problem with this patient's bone viability.
By the way, why did you get the MRI? Is there any evidence that MR imaging contributes to the management of such cases?
Best,
Peter
-----Original Message-----
From: ORT-L-owner@www2.aaos.org on behalf of Marek Kolasniewski
Sent: Tue 1/13/2009 11:20 PM
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] tibia infection after IMN
Dear Peter
I agree with you ( like with the others )that this patients may not require
many procedures besides debridement and stabilization (cast/EF/...). You
convinced me that he is no infected probably. I have one question finally.
You wrote :" Both (infection and presence of dead bone) would strongly
suggest failure with non-operative treatment". However I think that there's
dead bone in MRI scan. How is your opinion about it?
I'm very grateful to you for very interesting information.
p.s. My latest email has attachments with X-rays belong to the same ( BUT
ANOTHER) patient, preoperation ( presenting nonunion ) a 2 pictures postop (
with union ). I wanted to illustrate that in infected nonunion compression
with closed treatment may give us union and remission of infection.
If you are interested in I will glad to send you any further information
about this case.
Kinds Regards
Marek
-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Trafton, Peter
Sent: Tuesday, January 13, 2009 1:41 PM
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] tibia infection after IMN
Dear Marek,
I'm skeptical about the specificity of a post op MRI for distinguishing
between infection and aseptic post-operative changes - the tibia, now
re-fractured, has a medullary canal that was reamed m=not long ago and is
revascularizing, etc - and would certainly not be expected to appear
"normal" on MRI. I've operated on too many "certain abcesses" (according to
the radiologist) that have not been present at surgery, in spite of their
MRI appearance.
Thus I'm reluctant to treat this guy with a plan for mutliple aggressive
surgeries, unless I know he is truly infected, and (perhaps "or" as well) he
has convincing locally dead bone on both sides of the fracture. Both would
strongly suggest failure with non-operative treatment.
But his previous drainage went away, his fracture healed, his CRP does not
seem particularly high (I did neglect to ask about your lab's normals - and
it could be repeated for trend, now a week after your previous study). Also
he appears to have fractured through fairly mature, though recent, callus.
Is an MRI strong enough evidence for a recalcitrant infected nonunion (for
which several knowledgeable experts have given you excellent treatment
advice)?
If you wanted a simple, reliable test for a diffuse intramedullary
infection, you could aspirate, biopsy with long (e.g. bronchoscopy) forceps,
or even ream the canal and culture what you get - even then, a few bacteria
without classic signs of infection (which you tell us he HAD, but has no
longer) may tell us more about contamination than clinical infection. (You
will remember that the medullary blood supply usually reconstitutes during
fracture healing, so that reaming now sacrifices that - OK if infected,
probably not helpful if no infection. - just another thing to think about.
Furthermore, reaming "debulks" the medullary canal lining, but it certainly
does not radically debride - and will not touch any areas of greater
diameter than the isthmus, nor outpouchings like locking screw holes, etc.)
Again, I submit that if you try non-operative treatment and he heals
benignly, he'll be way ahead - and if he fails and infection flares, your
response should promptly be some variation of the the adequate debridement,
antibiotics, surgical stabilization and restoration of alignment and length,
so that he has a chance of good functional recovery.
I'm confused by the x-rays that accompany your latest email - they look like
a different patient's (higher fibula fracture, etc.).
Best wishes,
Peter
-----Original Message-----
From: ORT-L-owner@www2.aaos.org on behalf of Marek Kolasniewski
Sent: Tue 1/13/2009 1:27 PM
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] tibia infection after IMN
Peter
There's no major evidence that " this guy is still infected". I think that
in MRI we can see inflammation in canal in its hole length. This is the one
and only sign of infection in my opinion. I'm beginning to wonder if he
hasn't had infection, should I ( like Nikolaj Wolfson suggested ) use
cemented nail.. Probably ream the canal will remove all this intramedullary
secretion.
Nik
Thank for your answer. The :"cemented nail will turn into another foreign
body" explains to me many regardless of evidence of effectiveness using this
nail. ( probably effectiveness cemented nail is better in active infection,
but it my own opinion )
Jeff
I agree with you there is no evidence that any form of stabilization cure
(by itself ) infection, but appropriate stabilization of infection site will
promote union and healing process (also infection). I think compression
(good method of stabilization ) of site ( if there's no bone loss ) by
Ilizarov apparatus is good method of tx, especially in vital nonunions. This
is why I wrote that compress the fracture site is helpful in achieving
remission. On the other side we treat infected pseudoarthroses by closed
stabilization and compression with Ilizarov apparatus with good outcome. I
mean, probably by compression and proper stabilization we achieve union and
remission of infection too. I think this is possible if there is no dead
bone in infected site.
Ps. This 50 yo female with infected nonunion was treated by closed,
compression, stabilization in Ilizarov apparatus ( 9 months )
Kind regards
Marek Kolasniewski
Orthopedic and Trauma Unit
Military Hospital
Poznan
Poland
_____
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Trafton, Peter
Sent: Monday, January 12, 2009 7:58 PM
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] tibia infection after IMN
Sorry about my immediately preceding message - the emailer ate it!
it should read:
Hi Folks,
What evidence is there that this guy is still infected?
(in support of absolute stability of a fracture or nonunion that is
infected, I'd offer Willy Rittmann's (? with Stephan Perren) monograph about
internal fixation in the face of infection - old but good animal
experiments.)
However, the best treatment for this patient seems to be a matter of opinion
related to whether we think he is infected, or perhaps our philosophy about
whether infection can really be successfully suppressed / "cured".
Best,
Peter
_____
From: ORT-L-owner@www2.aaos.org on behalf of Trafton, Peter
Sent: Mon 1/12/2009 8:50 PM
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] tibia infection after IMN
Hi Folks,
What evidence is there that this guy is still infected?
(in support of absolute stability of a fracture or nonunion that is
infected, I'd offer Willy Rittman's (? with Stephan Perren) monograph about
internal fixation in the face of infection - old but good animal
experiments.)
However, the best treatment for this patient
_____
From: ORT-L-owner@www2.aaos.org on behalf of Alexander Chelnokov
Sent: Mon 1/12/2009 8:26 PM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] tibia infection after IMN
Dear Marek
2009/1/12 Marek Kolasniewski <kolix@wp.pl>:
> nonoperative tx but I'm convinced that infection requires permanent
> compression in order to achieve remission , so I'd prefer compression with
Instability is contributing factor for infection. So surgical
stabilization of fragments is mandatory. Of course compression is a
way to reach stability but not the only way. For this case
particularly it would be reasonable to restore length and alignment by
the Ilizarov or any other device of same purpose. Distraction will
increase stability. And then a nail should be locked in distraction,
preserving the "tension stress".
--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
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