Transform infected tibia
Courtesy of Dr. Ross Leighton, Orthopaedic Surgeon, Halifax, NS, Canada
60-year-old male involved in a motor vehicle accident presented with an isolated left open plafond fracture (Gustilo IIIA), ankle under compression and extensive soft tissue damage. CT scans indicated severe fracture of the distal tibia plafond and fracture lines with extensive comminution. External fixation was applied for 10 days.
A large partially dysvascular segmental piece on the medial side of the tibia was fixed with anterolateral plating and medial malleolar screw, and a lateral plate was applied to the fibula. At 3 months, the hardware construct loosened due to infection. Irrigation and debridement (I&D) was performed and screws were tightened. At 6 months, the patient underwent another I&D due to infection. 3 months later, the bone fracture appeared to be healing but culture samples tested positive for Staphylococcus aureus.
1 year after index surgery, initial fixation was removed and a tibiotalocalcaneal (TTC) nail was inserted to fuse the subtalar and ankle joints. I.V. and oral antibiotics were administered for infection control. 4 months later, another I&D was carried out for infection and proximal screws were removed due to backout from the construct.
At 1 year following stage 2 surgery, the fracture healed but infection persisted as osteomyelitis. The TTC nail was removed and 10cc STIMULAN bullets mixed with 240mg liquid tobramycin and 10cc STIMULAN bullets mixed with 1g vancomycin powder were inserted through the heel into the intramedullary canal to fill dead space and treat bacterial infection. I.V. antibiotics were administered for infection control.
1 year following stage 3 treatment, the subtalar joint and ankle joint were well-aligned and fused. Sed rate and C-reactive protein levels returned to normal and infection was eradicated with complete absorption of STIMULAN bullets. The patient remains pain and infection free and is walking and weight-bearing as tolerated.
Note: See STIMULAN page for regulatory statements. MA0447R1
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