Fig. 32.1
Open grade III multifragmental fracture of the right tibia. Anteroposterior view of 3D CT-reconstruction
Fig. 32.2
Lateral view of 3D CT-reconstruction
Fig. 32.3
Clinical picture at admission
The fracture was primarily stabilized with a medioventral external fixator with two Schanz screws inserted in the proximal and distal segments of the tibia. The wound was extensively debrided and cleaned by jet-lavage. Approximately 7 cm of devascularized tibia needed to be resected (Figs. 32.4 and 32.5).
Fig. 32.4
Postoperative anteroposterior radiograph. A medioventral external fixator has been inserted
Fig. 32.5
Postoperative lateral radiograph
The compartment syndrome was treated by extension of the open wound and fasciotomy. At day six post trauma, a secondary skin closure was performed (Figs. 32.6 and 32.7).
Fig. 32.6
Anteroposterior clinical picture after closure of fasciotomy
Fig. 32.7
Lateral clinical picture
Over the following 3.5 weeks, the fracture and wound healed to such an extent that intramedullary nailing with an antibiotic-coated tibia nail (Expert TN PROtect®, Synthes, Solothurn, CH) could be performed. The fibula was treated with a seven hole locking compression plate to restore the correct length of the lower limb. The external fixator was removed simultaneously. The Gentamicin-coated nail (9 mm × 375 mm) was implanted and locked statically (Figs. 32.8 and 32.9).
Fig. 32.8
Anteroposterior radiograph after insertion of a gentamycin-coated tibia nail and plate osteosynthesis of the fibula
Fig. 32.9
Lateral radiograph
Nine days later, the patient was discharged from hospital for rehabilitation. The soft tissues were in a good condition. There were at no time point any hints for infection neither at the skin nor in the blood samples. Partial weight bearing of 20 kg on the injured leg was allowed.
Eleven weeks after implantation of the antibiotic coated nail and smoking cessation, an Ilizarov ring fixator was applied for callus distraction to bridge the defect in the tibia. A proximal osteotomy was performed in the proximal third of the tibia. Five days after this operation, bone transport was started using the monorail-technique [32] (Figs. 32.10 and 32.11).
Fig. 32.10
Anteroposterior radiograph after application of Ilizarov external fixator and proximal tibia osteotomy for bone transport
Fig. 32.11
Lateral radiograph
During the next 3 months, bone transport was continued until the segment reached the docking site (Figs. 32.12 and 32.13). Consecutively, bone grafts from the iliac crest together with BMP-2 were inserted in the docking zone, which was additionally secured with a LC-DCP. The ring fixator was removed (Figs. 32.14 and 32.15).
Fig. 32.12
Anteroposterior radiograph at arrival of the bone segment at the docking site
Fig. 32.13
Lateral radiograph
Fig. 32.14
Anteroposterior radiograph after removal of the Ilizarov fixator, iliac crest bone grafting, BMP-2 application and protective plate osteosynthesis
Fig. 32.15
Lateral radiograph
One year after trauma, bone healing was achieved (Figs. 32.16 and 32.17).
Fig. 32.16
Anteroposterior radiograph at bone healing
Fig. 32.17
Lateral radiograph
There were several situations during the treatment of this patient, where the use of an antibiotic coated nail served well:
Severe III grade open tibia fracture with bone loss
One stage exchange from external fixation to an intramedullary device
Osteotomy of an injured leg after soft tissue damage
Bone transport by monorail-technique [32] using an ILIZAROV ring fixator
The availability of this Gentamicin-coated nail and the knowledge that bacterial growth is suppressed from the surface gave us the confidence to proceed with intramedullary nailing in this patient.
32.4 Clinical Evidence
The clinical use of antibiotic coated tibia nails was investigated in two prospective case series [20, 25]. In both series, no implant-related infections were observed in spite of the fact that the patient population was prone to develop an implant-related infection. Of the 27 patients, 20 presented with open fractures, 7 of which had a grade III° open fracture. At 6 months follow-up, 19 patients had healed fractures while fracture healing was progressing in the remaining 8.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
