Single-Stage Treatment Protocol for Presumed Aseptic Diaphyseal Nonunion.

INTRODUCTION: This article describes the general surgical technique for treating presumed diaphyseal nonunion with a one-stage procedure involving intraoperative removal of specimens for culture, revision open reduction and internal fixation (ORIF) with a plate or nail, and bone-grafting. STEP 1 PREOPERATIVE EVALUATION: Take a careful history, evaluate the extremity and wound, and note comorbidities and medications. STEP 2 PREOPERATIVE PLANNING: Preoperative planning is essential before revision nonunion surgery. STEP 3 DEBRIDEMENT IMPLANT REMOVAL AND CULTURES: Debride the nonunion site, remove all failed and loose implants, and take specimens for culture; withhold antibiotics until all culture specimens have been obtained. STEP 4 OPEN REDUCTION AND INTERNAL FIXATION: Reduce the fracture and use interfragmentary fixation and/or compression, or a bridging plate. STEP 5 POSTOPERATIVE CARE: If any of the five cultures are positive, consult an infectious disease specialist with experience in treating musculoskeletal infections. RESULTS: We have used this protocol at our institution for patients with prior fracture surgery who subsequently developed a nonunion, with or without implant failure, that had no obvious infectious etiology.IndicationsContraindicationsPitfalls & Challenges.

A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions: a review of outcomes.

OBJECTIVE: To review the results of a single-stage treatment protocol for presumptive aseptic diaphyseal nonunion with a well-healed wound and no infection history. DESIGN: Retrospective comparative study. SETTING: Tertiary referral center. PATIENTS AND METHODS: We retrospectively reviewed all presumptive aseptic diaphyseal nonunions treated by a single-stage protocol. There were 104 patients who met the inclusion criteria. Eighty-seven patients were available for follow-up through to complete healing (83.7% follow-up rate). INTERVENTION: The protocol entails withholding preoperative antibiotics, removing the implant, performing open debridement or canal reaming, taking 5 cultures of the nonunion site or canal reamings, followed by antibiotic administration, and revision open reduction and internal fixation or exchange nailing. If intraoperative cultures are positive, long-term antibiotics are begun specific to organism sensitivities. MAIN OUTCOME MEASUREMENTS: To analyze the rate of positive cultures and to compare the rate of secondary surgery to promote healing in positive and negative culture groups. RESULTS: Intraoperative cultures were positive in 28.7% (25/87) of patients with complete follow-up. The overall rate of secondary surgery for persistence of nonunion was 12.6% (11/87). In patients with positive intraoperative cultures, rate of secondary surgery was 28% (7/25) versus 6.4% (4/62) in the group without positive intraoperative cultures (P = 0.01). CONCLUSION: A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions was effective in obviating further revision surgery in 93.6% of truly aseptic cases and in 72% of positive culture cases and is still employed at our institution.