Algorithm 8 - Management of Infected Tibial Non-union

How to manage infected tibial Non unions ?

HiSTORY

History of infection post operatively

Chronic non healing draining sinus

Non responsive to oral antibiotics

Investigations

Inflammatory Markers persistently raised

X-ray

Non – union

            No cortical continuity

CT – confirm non union

            Look for sequestrum / dead bon e

MRI – abcess

Culture – Sinus fluid

Maagement

Cease smoking

Maximize nutrition

Optimize medical conditions

1) Ilizarov Technique

Remove metals

            Take multiple cultures

Ream/Irrigate

Apply Ilizarove

Manage non union

            Option 1 – Fibular Osteotomy

                        Acute compression over next 10 days

                        Weight bear as tolerated

                        Watch non union

            Option 2 – Exercise dead bone / non uion , +/- fibular osteotomy

                        Acutely shorten and compression distally

                        Proximal corticotomy and bone transport.

 Treat infection

            Appropriate iv antibiotics for 6 weeks

            Monitor inflammatory markers

2 )IM Antibiotics rod

            Remove metal work

            Make antibiotics rod

                        Chest tube with a guidewire in it

                        Poor PMMA with antibiotics (3 G Vancomycin, 3 G Flucolx )

                        Cut off plastic sleeve

                        Insert rod

            Treat infection

                        6/52 of appropriate antibiotics

            Definite management of Non union

                        Return at 6/52 for exchange nail / ilizarov

                        Bone grafting