"Super Late Infection" After Internal Fixation Of Fracture

Objective:to introduce the diagnosis and treatment of superadvanced infection after internal fixation of fracture.Methods:from October 2014 to October 2019,a total of 12 patients with "super advanced infection" after internal fixation were reviewed and treated,including 8 males and 4 females.Age: 32-78,mean age: 56.7;Cause of injury,9 cases of car accident injury,3 cases of fall injury.The infection occurred in 8 cases of femur(6 cases of fracture healing,2 cases of fracture unhealing),2 cases of tibia(1 case of fracture healing,1 case of fracture unhealing),and 2 cases of humerus(1 case of fracture healing,1 case of fracture unhealing).Among them,4 patients with unhealed fracture,3 without massive bone defect after debridement,and 1 with some bone defect.6cm Among the 12 patients in this group,9 had closed fractures and 3 had open fractures(type gustilo-anderson II).The initial internal fixation was intramedullary nail in 8 cases and plate in 4 cases.The time from initial internal fixation to infection was 1-30 years,with an average of 7.8 years.4 cases of patients with internal fixation plate were treated with internal fixation plate.Since the fractures of the patients had been healed,plate and screws were removed during the operation to remove infected bone and inflammatory granulation.2 cases of patients formed partial bone defect after debridement,and antibiotic bone cement was used to fill the bone defect after debridement.In 8 patients with intramedullary nail fixation,the intramedullary nail was removed before reaming and flushing the medullary cavity.For patients with concurrent sinus or abscess,the infected soft tissue should be removed at the same time.For focal or diffuse bone infection,local or whole sections of infected or necrotic bone are excised.After debridement,2 patients were implanted with antibiotic bone cement beads in medullary cavity,and the end of the beads was placed outside the skin.In the other 6 cases,antibiotic bone cement rods were implanted in the medullary cavity.All debridement surgery in patients with a closed wound,postoperative patients with intravenous drip sensitive antibiotics 2 weeks,4 weeks after oral instead,preoperative patients who were not do bacteria culture postoperative empirical application of vancomycin and levofloxacin,postoperative 1 week according to the results of bacterial culture to adjust the use of antibiotics,if intraoperative cultures for negative,continued use of vancomycin and levofloxacin 2 weeks,4 weeks after oral levofloxacin instead.Results: after 2 weeks,2-3 stitches were removed from the wound,and bone cement beads were removed from the bed.In one case,the fracture was not healed,and the bone scan 3 months after the operation showed that there was still nuclide concentration at the bone non-junction,segmental resection of the tibia was performed,and the bone defect was reached.Finally,the bone defect was reconstructed by biplanar osteotomy,and the bone defect was healed 16 months later.6cm Among the 6 patients with bone cement rods implanted in the medullary cavity,2 of them(1 case of humerus and 1 case of femur)did not heal,no nuclide concentration was observed in the bone scan 3 months after surgery,ESR and CRP were normal,the bone cement rods were removed,internal fixation and bone grafting were performed,and the fracture healed 6 months later.Bone scan,ESR and CRP of 4 patients with healed fractures showed no obvious abnormality 6 months after surgery,among which 3 patients had bone cement rod removed,and 1 patient had no bone cement rod removed.Results:All the 12 patients in this group were followed up for more than 1 year,and all the patients were healed by the last follow-up,without any recurrence of infection.Conclusions: there is no significant difference in symptoms and signs between late infection,delayed infection and late infection after internal fixation of fracture.Because of the presence of internal fixation,bone scanning is of great significance in the diagnosis of ultra-advanced infection.Smoking,open fractures,previous use of external fixators,and diabetes are all risk factors for advanced infection.For patients with diabetes,it is recommended to remove internal fixation early after fracture healing to avoid super-advanced infection.More cases are needed.