| Posttraumatic osteomyelitis is described as an inflammation of the bone marrow and surrounding cortical bone caused by open fractures, firearm injuries, and contamination in the surgery. With developments of the society, especially fast developments of the building and traffic industry, open fractures caused by high-energy injuries increase rapidly. Together with the abnormal popularity of internal fixations, the incidence of posttraumatic osteomyelitis increases. In case of posttraumatic osteomyelitis, the infections can lead to adverse effects on union of fracture, and inversely the instability of the fracture can lead to adverse effect on the control of infections. The interaction of these factors increased the difficulty of treatment. The clinical results were poor, and in some cases, posttraumatic osteomyelitis can cause severe functional deficiency and life-threaten. Posttraumatic osteomyelitis is a great challenge to the orthopedic surgeons.The objective of this study is to find out the most efficacious treatment for posttraumatic osteomyelitis with the principles of surgical infection treatment. The contents include: (1) infected long bone defects treated by internal bone transport using the external fixation. (2) the use of antibiotic-impregnated cement rods to treat intramedullary infections after nailing, (3) experimental study of the effect of Vancomycin-calcium sulfate on chronic staphylococcal osteomyelitis.1. Infected long bone defects treated by internal bone transport using the external fixationMaterials and Method Thirty-two cases of infected long bone defects were treated by internal bone transport using the external fixation between 2002 and 2005. There were 25 males and 7 females with an average age of 34.6 years (range 18-60 years). Involved bones included femur in 7 cases and tibia in 25 cases. According to the Cierny-Maderde classification system, all of the cases were grade IVA osteomyelitis. The duration of infection ranged from 6 months to 30 months, averaged 15.6 months. All of these cases had varied degrees of bone defects, sinuses, and wounds. Secretion-culture verified that infecting organisms included staphylococcus aureusand Pseudomonas aeruginosa in most of the cases. Treatment Intravenous antibiotics therapy was taken 3-7 days before the surgery. Thorough debridement was accomplished in the operation, and the wounds were treated with one-stage or two-stage soft-tissue flaps coverage. In some cases, the wounds were treated with Orr's method. In this group, Ilizarov circular frame was used in 19 cases, Orthofix LRS (limb reconstruction system) external fixator was used in 13 cases. Single-level osteotomy was performed in 28 cases, and two-level osteotomy in 4 cases. In the tibial site, corticotomy was used, and in the femoral site, standard osteotomy was performed. The key point of osteotomy was the protection of integrity of periosteum. Postoperatively. intravenous antibiotics therapy was stopped after getting of 3 weeks normal body temperature. Bone transport was performed I week postoperatively with one millimeter everyday at twice. Debridement at the docking site was performed in 30 cases. Twenty-one of the 30 cases underwent autogenous iliac cancellous grafting at the docking site. After getting good bony union at the docking site and distraction site, external fixator could be kept in place, or be replaced by plaster or brace fixation. In the group, plaster fixation was used in 12 cases, and brace in 17 cases. Patients could do partial weight-bearing and joint functional exercises with the external fixators in place. Full weight-bearing should be avoided for 6 months after removal of external fixator. Results The average time of follow-up of the 32 patients was 13 months (range 7-24 months). Infections were controlled in 25 patients (78.13%) within a mean of 5 months (range 3-8months). Of the 7 patients with uncontrolled infection, one patient underwent amputation, four patients had local sinuses, two patients had pain of the involved limb. Except of one underwent amputation, twenty-nine of the 31 patients got bony union with a mean time of 8.8 months (range 5-16 months). The average RCI (radiographic consolidation index) was 1.6 months. The average EFT (external fixation time) was 7.9 months (range 5-12 months). The wounds in 5 patients were closed in one-stage operation, and two of them haven't healed. Among the 8 wounds treated by two-stage operation, one of them had sinuses until now. Nineteen wounds were treated with Orr's method, and two of them haven't healed. During the distraction procedure, none of the patients had complications of nerve or blood vessel injuries. Nineteen patients had pin tract infections, two patients suffered refractures at the docking site following removal of the external fixator. According to the modified classification system of the Association for the Study and Application of the Method of Ilizarov (ASAMI), the functional results were rated as excellent in 21 cases, good in 6 cases, and poor in 5 cases. Of the 19 patients treated with Ilizarov external ilxator, 14 patients (73.68%) got infection controlled with an average of 5.36 months (range 3-8 months). Bony union was obtained in 17 of the 19 patients (89.74%) with a mean of 9.18 months (range 5-16 months). Eleven of the 13 patients (84.62%) treated with Orthofix LRS external fixator got infection controlled with a mean of 4.55 months (range 3-6 months). Among the 13 patients, twelve (92.31%) got bony union with a mean time of 8.33 months (range 5-16 months).In the two groups, the most common complication was pin tract infection with the incidence of 63.16% (12/19) and 53.85% (7/13) respectively. Two cases had refractures in the group treated with LRS external fixator. Seventeen of the 19 patients (89.74%) treated with Ilizarov external fixator got excellent or good results. In the Orthofix LRS external fixator treated group, ten of the 13patients (76.92%) got excellent or good results. Statistical analysis showed that there were no significant differences between the two groups on the listed indexes in the results. Conclusions (1) Internal bone transport using the external fixation is an efficacious treatment for infected long bone defects, this method can get good results of infection control and bony union. (2) Radical debridement of all necrotic and nonviable bone and soft tissue from the wound is the key point for getting good results. (3) Dynamic Orr's therapy is a valuable method to treat infected bone defects with large soft tissue loss. (4) Orthofix LRS external fixator and Ilizarov circular frame external fixators both can accomplish internal bone transport and get good bony union. When using LRS external fixator, it is larger possibility of emerging axial migration of the transported bone. (5) This method has drawbacks of long course of treatment and high complication of pin tract infection, it need the patient' s cooperation and well-nursing after surgery.2. Use of Antibiotic-impregnated Cement Rods to Treat Intramedullary Infections after NailingMaterials and Method From January 2003 to August 2005, treatment of intramedullary infections after nailing with antibiotic-impregnated bone cement were carried out in 19 patients. There ware 16 males and 3 females with a mean age of 38.4 years (range 20-78 years). The involved bones included femur in 6 cases and tibia in 13 cases. The mean time of infection after nailing was 9.3 months (range 2-23 months). Of these cases, three had union of fractures, fourteen had non-union of the fractures without bone defect, and two had non-union of the fractures with bone defects. According to the Cierny-Maderde classification system, three cases were grade I A, and 16 cases were grade IVA. Seventeen cases had sinuses at the fracture site (11 cases) and the locking screw site (6 cases). Sixteen patients had bacteriology examination, and 11 got positive results. Infecting organisms included staphylococcus aureus and Pseudomonas aeruginosa in most of the cases. Intravenous antibiotics therapy was taken 3-5 days before the surgery. In the operation, thorough debridement and reaming were performed. The ultimate reamer used in theses cases was 2 mm larger in diameter than that in normal cases. It was 10-13 mm in diameter at the tibial intramedullary canal and 12-14 mm at the femoral. Copious irrigation was carried out with pulsed-wave rinser, and an average of 7370 ml (3000-12000 ml) rinse solution was used. Vancomycin-impregnated bone cement was made by mixing 40-80 g bone cement (PMMA) with 2-4 g vancomycin, the concentration of Vancomycin was 5%. Then vancomycin-impregnated bone cement rods were made with the diameter of 2-3 mm less than the last reamer and the equal length of the Intramedullary nails, the maidre of the rods were guide pin of 3 mm in diameter. After insertion of the cement nail, the wounds were closed at one-stage operation (2 cases), two-stage soft-tissue flaps coverage (5 cases). The other 7 cases were treated with Orr's method. In the cases of nonunion, external fixations and / or plaster cast were used. Postoperatively, intravenous antibiotics therapy was stopped after getting 3 weeks of normal body temperature. After control of the infection, the cement rods were removed, andreplaced with normal intramedullary nails. The control group from January 2003 to August 2005, consisted of treatments of intramedullary infections after nailing with other methods. There ware 7 patients (6 males and I female) with a mean age of 36.3 years (range 23-61 years). The involved bones included femur in 2 cases and tibia in 5 cases. The mean time of infection after nailing was 8.7 months (range 4-15 months). Of these cases, one had union of fracture, five had non-union of the fractures without bone defect, and one had non-union of the fracture with bone defect. According to the Cierny-Maderde classification system, one case was grade I A, and 6 cases were grade IVA. All of the 7 cases had unclosed wounds or sinuses. Intramedullary irrigation and suction drainage was wused in 5 cases after radical debridement. In the other cases, only Intramedullary drainage was used. In the 6 cases with nonunion of the fractures, five applied external fixators, and one had plaster cast. The treatment of the wounds and the antibiotics therapy were similar in both group. Results In the group treated with bone cement rods, the mean time of follow-up was 14.2 months (range 4-31 months). Sixteen of the 19 patients got control of the infection with an average 4.44 months (range 2-8 months) course of treatment. Of the 3 patients with uncontrolled infection, one patient got control of infection with another intramammary debridement and insertion with the vancomycin -impregnated bone cement rod, one patient gave up anymore surgical treatment, and the other one underwent amputation because of functional deficiency of the involved limb. In one of the 19 cases, bone cement rod was blocked when inserting, it was pulled out with opening partial of the medullary cavity. Two of 19 bone cement rods broke. One patient had knee joint infection. In the control group, the mean time of follow-up was 16.2 months (range 7-36 months). Control of the infection achieved in 4 cases with an average time of 9.3 months (range 5-15 months). One patient underwent amputation. The other 2 cases had sinuses locally. Statistical analysis was done with SPSS 10.0 software, the cure rate had no significant difference between the two groups (P > 0.05), and the course of treatment had significant difference between two groups (P < 0.05). Conclusions (1) Treatment of the intramedullary infections after nailing with antibiotic-impregnated bone cement rods is a method consistent with the principles of surgical treatment of infection. (2) Compared with the control group, antibiotic-impregnated bone cement rod can get higher rate of infection control and shorten the cause of treatment. (3) The method of treating the intramedullary infections after nailing with antibiotic-impregnated bone cement has its complication, it is important to pay attention to match the rod with the medullary cavity, protect the fracture site after surgery, and prevent infection of the adjacent joint.3> Vancomycin-calcium sulfate for chronic osteomyelitisObjective To investigate the effect of Vancomycin-calcium sulfate on chronicstaphylococcal osteomyelitis healing,compared with Vancomycin- polymethylmethacrylate(PMMA ) . Methods In the current work, 24 rabbits were chosen to set up animal model ofchronic osteomyelitis in left tibiae. X- rays of the infected tibiae,the changes of weight.observations of infected tibiae and S.aureus cultures were examined for evidence of osteomyelitis.and S.aureus cultures were golden standard. Animals were randomly dispatched to one of the three treat groups:A bank,B bank and C bank;After surgical debridment,A bank received polymethylmethacrylate implant.B bank received Vancomycin- polymethylmethacrylate implant and C bank received Vancomycin-calcium suifate implant.Drainage fluid and blood of B bank and C bank were collected(0.5h, l.Oh, 1.5h, 2.0h, 4h, 6h, I2h, 24h, 48h...after operation)to measure the Vancomycin levels;The urine of B bank and C bank were also been collected(lh, 2h, 6h, 12h, 24h, 48h, 4d,7d...).AII rabbits were weighted. In every bank,eight rabbits were dispatched to one of the four groups,and euthanasia occurred at 15 days^ 30 days, 45 days, 60 days after operations;All rabbits were weighted, S.aureus cultured and observed again.bone and muscle were cutted to do inhibition zone test. Results Osteomyelitis was obtained in 24 of the 24 animals (100%). Antibiotic release in C band was more stable than in B band and the Vancomycin level of C band was higher than B band(P<0.05),but in blood and urine.both B and C band were low than in drainage fluid. The mortality of B and C bands were 0%,but A band was 62.5%;The positive of S.aureus culture of A band was 87.5 %,B band was 25 % and C band was 0%;And inhibition zone test of bone and muscle showed that B band was better than A band and the antimicrobial activity of both bands were continued until 2 months later. Conclusion The effect of Vancomycin-calcium suifate on chronic staphylococcal osteomyelitis healing is better than Vancomycin- polymethylmethacrylate.SummryThorough debridtnent, ablation of dead space, stabilization of the fracture, and control of infection though antibiotics use have been and will be treatment principles of posttraumatic osteomyelitis.
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