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When and How to Intervene Surgically in the Infected Fracture
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When and How to Intervene Surgically in the Infected Fracture
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Segment:0 .
BILAL JAMAL: So it's a great pleasure for me to introduce Hamish Simpson, who is the Professor of Orthopedics in Edinburgh. In addition to that, he's taken on a number of roles nationally and internationally and has been president of multiple learned societies. As I'm sure everyone in the audience is aware, he is also Editor in Chief of the Bone and Joint Research Journal, the BJR, and he's the senior most limb reconstruction surgeon in the United Kingdom and luckily for me, is only 40 miles to the east of where I work and therefore is on the receiving end of multiple questions from me to try and help me manage clinical issues.
BILAL JAMAL: So it's an absolutely huge pleasure to introduce Hamish and ask him to speak on the surgical management of the infected fracture. Thank you Hamish.
HAMISH SIMPSON: Thanks very much, Bilal. Let me just see if I can share these successfully. Is that showing successfully? Now It looks good. Yes, it is good. OK. So what I was going to cover today is a little bit of particularly how to, when to intervene in fracture related infection and a few things about how to intervene.
HAMISH SIMPSON: But I think it's often actually deciding the timing to intervene is particularly difficult. As Bilal says, this is just my disclosures.
HAMISH SIMPSON: And inventory for this, we get some departmental funding, but there's no conflicts relevant to this talk. So there are some overriding priorities in fracture related infection to save life in terms of necrotizing fasciitis and other situations if there's vascular compromise for saving the limb. But then there's a lot of other cases we see, such as one like this, an early mild wound redness without any kind of deep haematoma or other swelling and with a stable fracture fixation where if it's within the first kind of week, 10 days, I think the majority probably would not actually intervene straight away in a case like this.
HAMISH SIMPSON: There's others such as this case from Cheng Jiangling and others, where it's kind of nine months painful still and discharging open wound, and I think the majority of us would actually think it's time to actually do something to intervene in this patient. But then there's other cases where we have an X-ray as shown on the right there where there's some kind of periosteum, there's still a leaking wound,
HAMISH SIMPSON: but would we actually all kind of rush in on that one or would we kind of do something else. And I'll come back to this case a bit later on. So when should we intervene? Or is time the main determinant for this. Is that the thing that should actually tell us whether or not we need to intervene? And certainly when we were planning a workshop on infections and the kind of treatment algorithms. Our initial draft had three talks, one from acute infections, 0 to 4 weeks, intermediate 1 to 6 months, and then chronic more than six months.
HAMISH SIMPSON: And others such as kind of Trampuz and Zimmerli have also considered that the infection should be divided up according to whether they're early, less than two weeks, delayed two to 10 weeks or late more than kind of10 weeks. And as has been alluded to already by kind of Neil Ritchie, time is clearly very important in terms of things like the organisms that we grow. I think you mentioned the Wang and Corrigan studies.
HAMISH SIMPSON: It's also in terms of the route that the infection is likely to have reached the deep structures. It also is important, not necessarily from the infection side, but also about the construct stability and the chance of retrieving unions. So time is clearly an extremely important factor, but what I'd like to suggest is it's perhaps not the most important in terms of working out whether or not we need to intervene.
HAMISH SIMPSON: And certainly if we look at it just from the biofilm stage of things, the biofilms have actually formed within a matter of hours to days and so if we were doing it on the basis of what's happening deep inside the infection, even by the time of 10 days, it's probably kind of already become a chronic situation from the bacteria's point of view. And indeed, if you look at this, this is a review we did on total hip replacement procedures for total hip.
HAMISH SIMPSON: It looked as if there was an infection around about seven days, suggesting that, in fact, your chance of success, if you were going to be doing a DAIR in prosthetic joint infection, can have reduced after seven days. Although, interestingly, it still remained at a reasonable level for quite a prolonged period of time. So if it's not time for, say, perhaps this, what we should be doing is just asking ourselves five questions and to ask ourselves these five questions at any time during the procedure.
HAMISH SIMPSON: And if the answer is yes to any of these, then we would need to intervene. So first of all, skin. Is the bone covered, because we all know that if the bone is exposed, then it will die and so dry bone is dead bone. So the one thing I've just mentioned to this, when you'll be doing this in often in conjunction with your kind of plastic surgery colleagues, but the thing that you need to actually chat to plastic surgery colleagues about is the amount of bone that you're going to excise and in particular, whether the soft tissue defect is going to be less than the bone defect because then that opens up other opportunities for you, in particular acute and gradual shortening with Ex Fix luxation or intramedullary means.
HAMISH SIMPSON: The other thing just to mention in this is just not to forget the reverse z-plasty and if you do have to explore something such as an infected nonunion, I commend this to you because this type of flap, if you kind of do it, gives you fantastic exposure to the bone ends and working out what you need to excise, but also gives you the opportunity. This is just showing on this in here is that you can either decide to reposition the flaps as originally as they were originally, or if you've had to shorten the limb quite significantly, you can then transpose the flaps using this reverse z-plasty
HAMISH SIMPSON: so you're using the shape of the incision to gain width rather than length with this. And this is what we did on this case. Now, this is a case that I've just taken from the internet here from Goodyear and Calder, but is an indication that with the modern nails that we have, you can carry out this kind of shortening procedure in a gradual kind of route rather than it being necessarily be having to be done with a frame.
HAMISH SIMPSON: The next question we need to ask is, is the alignment satisfactory? And going along with that, is it better to correct it post union as it may be in certain cases. After this, the next one is infection. Can the infection be controlled? And this, I think, depends on whether there's extensive dead bone or primarily, whether on the implant, whether the infection is on the dead bone or the implant.
HAMISH SIMPSON: Whether local antibiotics can may be useful for controlling the dead space, and which Bilal has just alluded to, but also in these ones, if you're shortening and you want your actual kind of the dead space management, your dead space is being reduced as you're gradually shortening. Adjusting the bead size can be extremely helpful in working out the rate that the Stimulan or your other product is actually disappearing.
HAMISH SIMPSON: So it can actually change the rate that you, your dead space is filled by your filler. And finally, just to think about inhibition of healing by infection or by the antibiotics. And inhibition of the healing by infection, I think there's a couple of things I wanted to mention here. One is that this is actually a osteoblast here engulfing bacteria and the bacteria are directly kind of poisoning this osteoclast.
HAMISH SIMPSON: And that's clearly a massive importance for primary bone healing where the osteoblasts are being kind of prevented from doing their action by these bacteria. But the other thing that happens is that the bacteria are likely to cause a persistence of the inflammatory state and that's particularly important for indirect fracture repair, where if you can't get rid of your inflammatory phase, it's impossible to progress on to the next phase
HAMISH SIMPSON: so there are these two ways I think the infection is actually blocking the [MUSIC PLAYS] entry stage. But as well as the infection inhibiting healing, we have to be aware that the antibiotics that we give can also inhibit fracture repair. And there's pretty good evidence for this, for things like Ciprofloxacin and also for Levofloxacin, Trovafloxacin, where in vivo animal models they've demonstrated a complete block to healing.
HAMISH SIMPSON: Now in cell culture, the Ciprofloxacin, Rifampicin, Gentamycin, Gentamycin have all been shown to inhibit osteoblasts, and that might be therefore relevant, particularly in, say, primary bone repair, but perhaps not so much in the secondary bone repair. But the key thing is that clearly we need to control the infection, therefore we need to give the antibiotics, but is just to be aware that if we give very high doses for a long period of time is just to keep an eye on our fracture repair process in case there's inhibition of that by the treatment we're giving.
HAMISH SIMPSON: The next question I think we need to ask ourselves is whether our construct that we've got we have on there will stabilize the fracture to union. And you can see in this case here, there has already begun to be some loosening of the implant and it's unlikely that this will stabilize to unions. So with this infection here, it was better to intervene at this stage
HAMISH SIMPSON: and actually, we chose to put on a longer plate and do a Mascoli technique for this one rather than wait for this to, to fail. But if the construct will stabilize the fracture to union, then it may be possible to carry out either just, either just to suppress the infection or to carry out a DAIR procedure. So in terms of the revision procedures for FRI, I think just a few kind of principles.
HAMISH SIMPSON: One is that it's clear that we need to obtain stable fixation because that helps control the infection. There's work from several kinds of studies, particularly in models from in rabbits and hamsters showing that if you've got instability, it's very difficult for the body to control infection, whereas if you have stability, it's a lot easier to control infection. The second principle I'd suggest is that we don't contaminate an uncontaminated canal.
HAMISH SIMPSON: If the initial treatment has been with intramedullary nailing the canal is compromised and if you put a further intramedullary nail down, I don't think it is actually a problem. But if it hasn't been, if it's been a plate fixation, then I certainly prefer not to actually put a nail down to spread infection up and down the canal. And the other things, principle would be to minimize hardware, the hardware at the site of infection and to cover with local antibiotics.
HAMISH SIMPSON: So next thing is in terms of our union and find things, can we achieve union? And this depends, I think, on which strategy that we're going for and it's just to remind you that with fracture related infection, there's two interrelated orthopedic problems. One is deep bone infection and the other is a failure of fracture healing.
HAMISH SIMPSON: And the strategies you can either go for are to treat the fracture, then infection. Next one is to, first of all, treat the infection definitively and then the fracture, then to do both at the same time, which you would do if you were doing an acute shortening procedure. And finally, to do neither, which is to carry out an amputation, which again, as Neil has pointed out, happens in about 3% of the FRI cases. If possible, though, I suggest that you go for (a) which is to try and treat the fracture first and then the infection
HAMISH SIMPSON: because if you can get union, it is a lot, you can often carry out a less morbid procedure for the patient than if you actually kind of try if you go for these other options. So can union be obtained or even can union of part of the fracture be obtained? Because if you can achieve union of the articular component of a fracture, that can often again reduce the morbidity that's needed for the review of your option for final treatment.
HAMISH SIMPSON: In terms of whether you can, a DAIR procedure is likely to be successful. The smoking is one of the main things that reduces the chance of success. Smoking in general kind of reduces the chance of getting a union, but these colleagues in by Ritemire et al in 2008 pointed out it was a 3.7 times rate of failure if patients were smokers.
HAMISH SIMPSON: But the key thing, I think, is to monitor regularly and actually kind of deeper allude to this as well, that for us the CT scan is extremely useful for monitoring whether or not the healing is progressing, and we'll often have 6 to eight weeks get CT scans rather than plain films for monitoring whether or not the bone is healing. And this was just to show you this case, I showed you earlier on.
HAMISH SIMPSON: In fact, we chose not to intervene. We just put the person into a sarmienta cast, gave them some oral flucloxacillin until the actual bone had united, removed the metal work and then actually just reamed out the canal and the person need no needed, no further treatment. So a minimum kind of morbid morbidity process that compared to a wide excision at the site. In terms of trying to predict, though, whether or not this will work.
HAMISH SIMPSON: This is some work from that we wrote up with Jerry Tsang and others in terms of looking at whether or not there was a periosteal reaction at the fracture site. And in this case, there's no periosteal reaction, but here you become to see there is a periosteal reaction. And if there is a periosteal reaction, there's a far greater chance that with an exchange nailing procedure, the patients will go on to unite
HAMISH SIMPSON: so a five times relative risk of failure in accepting non unions if there is no periosteal reaction. So finally, when should we intervene surgically? This was just showing for this type of case, though, which achieves all of these five questions. The skin cover is inadequate, the position isn't adequate. I think you wouldn't want to accept this kind of position up here.
HAMISH SIMPSON: The infection kind of is not possible to control and the, we're not going to be able to hold this position to unions. So with all of these, this person was actually kind of treated, I think, very appropriately with a wide excision here and a switch to a frame to actually kind of obtain union. So in just two slides can conclude with. To me, in terms of when we should intervene surgically, I think there's five questions to ask
HAMISH SIMPSON: and if the answer to any of these is yes, is no at any time, then we should intervene. So first of all, skin. Is there adequate skin cover? Position. Is that satisfactory? Infection. Can it be suppressed to union and construct; will that hold the kind of bone to union and can union be obtained without further intervention. In terms of the principles, I think the skin; just the only thing is to remember the possibilities of acute and gradual shortening, particularly if the skin defect is less than your bone defect.
HAMISH SIMPSON: The position. I think it's frequently, it's possible to correct the shortening post union, but only occasionally do we correct alignment post union. If you can get your bone kind of healed in a good alignment, but just short, it's a relatively simple procedure then to regain length. Infection. Infection versus antibiotics is just to be aware of these conflicting things. It's clearly vitally important to control the infection
HAMISH SIMPSON: therefore, I, we will be using antibiotics, but just to be aware and to monitor whether or not they could be inhibiting the healing. And as I mentioned, local antibiotics, particularly useful and can titrate the bead size for the time that you want your dead space filler to be present. And in terms of the principle for if you've got to change your construct is just not contaminate an unadulterated canal.
HAMISH SIMPSON: And finally, if possible, go for union first strategy but to monitor very carefully with CT to see whether or not you're going to be able to achieve that. And I'll with that, I'll close. Thank you very much for your attention.
BILAL JAMAL: Hamish, that was, as ever, a phenomenal talk. In particular, thank you for the clarity of thought to there. One of the things that I wanted to clarify was around timing of surgery in that I suppose this group of patients presents in one of two fashions. There's a group of patients who present to clinic, for example, and they've had grumbling infection and problems consequent upon that, and they can be added to a semi-elective list, as it were.
BILAL JAMAL: But there's another group of patients who present in an urgent fashion and are admitted. What do you think the time frames should be for these group of patients having their surgery and who should do it and when should they be temporised with antibiotics till the situation settled down. So I'd just like to explore timings around surgery and a bit more detail, if you don't mind.
HAMISH SIMPSON: In terms of the question of who it should be done by I mean, I think all of these are consultant cases. I mean, they're not. a lot of them are very difficult decisions
HAMISH SIMPSON: so they should be consultant cases. In terms of the timing, I mean, I think one of the things is if you've got there's an acute inflammatory process going through the cellulitis, then it may well be that they can just be admitted for antibiotics and you don't actually have to intervene surgically for those ones. We will get an ultrasound, possibly an MRI but as Deepa's mentioned, the problem with MRI, if there's a lot of metalwork in there, it often can't actually tell you whether or not there's this pus that needs draining.
HAMISH SIMPSON: If there's pus that needs draining, then we will take them to theater for that. But if it's just a cellulolytic thing, we will just give antibiotics and then it comes back to the question, I think can we suppress the infection to union or do we need to intervene to get union? So it comes back to me those five questions rather than actually say that we have to go in and we have to change because if you do go in early, you will often end up doing a very wide resection.
HAMISH SIMPSON: You're then committing the person to potentially a bone transport procedure and months of treatment. So that's why, if at all possible, I'll go for the union first strategy. I'll try to avoid doing kind of a radical procedure, but at the same time monitoring very carefully and if we've got, if we're stagnation of healing, then you must intervene.
BILAL JAMAL: So thank you. That's really useful. I wanted to just add a couple of things before we finish up for the evening, the first of which was to again, thank our corporate supporters without whom this webinar series wouldn't be feasible. And there's Dr. Richard.
Segment:0 .
BILAL JAMAL: So it's a great pleasure for me to introduce Hamish Simpson, who is the Professor of Orthopedics in Edinburgh. In addition to that, he's taken on a number of roles nationally and internationally and has been president of multiple learned societies. As I'm sure everyone in the audience is aware, he is also Editor in Chief of the Bone and Joint Research Journal, the BJR, and he's the senior most limb reconstruction surgeon in the United Kingdom and luckily for me, is only 40 miles to the east of where I work and therefore is on the receiving end of multiple questions from me to try and help me manage clinical issues.
BILAL JAMAL: So it's an absolutely huge pleasure to introduce Hamish and ask him to speak on the surgical management of the infected fracture. Thank you Hamish.
HAMISH SIMPSON: Thanks very much, Bilal. Let me just see if I can share these successfully. Is that showing successfully? Now It looks good. Yes, it is good. OK. So what I was going to cover today is a little bit of particularly how to, when to intervene in fracture related infection and a few things about how to intervene.
HAMISH SIMPSON: But I think it's often actually deciding the timing to intervene is particularly difficult. As Bilal says, this is just my disclosures.
HAMISH SIMPSON: And inventory for this, we get some departmental funding, but there's no conflicts relevant to this talk. So there are some overriding priorities in fracture related infection to save life in terms of necrotizing fasciitis and other situations if there's vascular compromise for saving the limb. But then there's a lot of other cases we see, such as one like this, an early mild wound redness without any kind of deep haematoma or other swelling and with a stable fracture fixation where if it's within the first kind of week, 10 days, I think the majority probably would not actually intervene straight away in a case like this.
HAMISH SIMPSON: There's others such as this case from Cheng Jiangling and others, where it's kind of nine months painful still and discharging open wound, and I think the majority of us would actually think it's time to actually do something to intervene in this patient. But then there's other cases where we have an X-ray as shown on the right there where there's some kind of periosteum, there's still a leaking wound,
HAMISH SIMPSON: but would we actually all kind of rush in on that one or would we kind of do something else. And I'll come back to this case a bit later on. So when should we intervene? Or is time the main determinant for this. Is that the thing that should actually tell us whether or not we need to intervene? And certainly when we were planning a workshop on infections and the kind of treatment algorithms. Our initial draft had three talks, one from acute infections, 0 to 4 weeks, intermediate 1 to 6 months, and then chronic more than six months.
HAMISH SIMPSON: And others such as kind of Trampuz and Zimmerli have also considered that the infection should be divided up according to whether they're early, less than two weeks, delayed two to 10 weeks or late more than kind of10 weeks. And as has been alluded to already by kind of Neil Ritchie, time is clearly very important in terms of things like the organisms that we grow. I think you mentioned the Wang and Corrigan studies.
HAMISH SIMPSON: It's also in terms of the route that the infection is likely to have reached the deep structures. It also is important, not necessarily from the infection side, but also about the construct stability and the chance of retrieving unions. So time is clearly an extremely important factor, but what I'd like to suggest is it's perhaps not the most important in terms of working out whether or not we need to intervene.
HAMISH SIMPSON: And certainly if we look at it just from the biofilm stage of things, the biofilms have actually formed within a matter of hours to days and so if we were doing it on the basis of what's happening deep inside the infection, even by the time of 10 days, it's probably kind of already become a chronic situation from the bacteria's point of view. And indeed, if you look at this, this is a review we did on total hip replacement procedures for total hip.
HAMISH SIMPSON: It looked as if there was an infection around about seven days, suggesting that, in fact, your chance of success, if you were going to be doing a DAIR in prosthetic joint infection, can have reduced after seven days. Although, interestingly, it still remained at a reasonable level for quite a prolonged period of time. So if it's not time for, say, perhaps this, what we should be doing is just asking ourselves five questions and to ask ourselves these five questions at any time during the procedure.
HAMISH SIMPSON: And if the answer is yes to any of these, then we would need to intervene. So first of all, skin. Is the bone covered, because we all know that if the bone is exposed, then it will die and so dry bone is dead bone. So the one thing I've just mentioned to this, when you'll be doing this in often in conjunction with your kind of plastic surgery colleagues, but the thing that you need to actually chat to plastic surgery colleagues about is the amount of bone that you're going to excise and in particular, whether the soft tissue defect is going to be less than the bone defect because then that opens up other opportunities for you, in particular acute and gradual shortening with Ex Fix luxation or intramedullary means.
HAMISH SIMPSON: The other thing just to mention in this is just not to forget the reverse z-plasty and if you do have to explore something such as an infected nonunion, I commend this to you because this type of flap, if you kind of do it, gives you fantastic exposure to the bone ends and working out what you need to excise, but also gives you the opportunity. This is just showing on this in here is that you can either decide to reposition the flaps as originally as they were originally, or if you've had to shorten the limb quite significantly, you can then transpose the flaps using this reverse z-plasty
HAMISH SIMPSON: so you're using the shape of the incision to gain width rather than length with this. And this is what we did on this case. Now, this is a case that I've just taken from the internet here from Goodyear and Calder, but is an indication that with the modern nails that we have, you can carry out this kind of shortening procedure in a gradual kind of route rather than it being necessarily be having to be done with a frame.
HAMISH SIMPSON: The next question we need to ask is, is the alignment satisfactory? And going along with that, is it better to correct it post union as it may be in certain cases. After this, the next one is infection. Can the infection be controlled? And this, I think, depends on whether there's extensive dead bone or primarily, whether on the implant, whether the infection is on the dead bone or the implant.
HAMISH SIMPSON: Whether local antibiotics can may be useful for controlling the dead space, and which Bilal has just alluded to, but also in these ones, if you're shortening and you want your actual kind of the dead space management, your dead space is being reduced as you're gradually shortening. Adjusting the bead size can be extremely helpful in working out the rate that the Stimulan or your other product is actually disappearing.
HAMISH SIMPSON: So it can actually change the rate that you, your dead space is filled by your filler. And finally, just to think about inhibition of healing by infection or by the antibiotics. And inhibition of the healing by infection, I think there's a couple of things I wanted to mention here. One is that this is actually a osteoblast here engulfing bacteria and the bacteria are directly kind of poisoning this osteoclast.
HAMISH SIMPSON: And that's clearly a massive importance for primary bone healing where the osteoblasts are being kind of prevented from doing their action by these bacteria. But the other thing that happens is that the bacteria are likely to cause a persistence of the inflammatory state and that's particularly important for indirect fracture repair, where if you can't get rid of your inflammatory phase, it's impossible to progress on to the next phase
HAMISH SIMPSON: so there are these two ways I think the infection is actually blocking the [MUSIC PLAYS] entry stage. But as well as the infection inhibiting healing, we have to be aware that the antibiotics that we give can also inhibit fracture repair. And there's pretty good evidence for this, for things like Ciprofloxacin and also for Levofloxacin, Trovafloxacin, where in vivo animal models they've demonstrated a complete block to healing.
HAMISH SIMPSON: Now in cell culture, the Ciprofloxacin, Rifampicin, Gentamycin, Gentamycin have all been shown to inhibit osteoblasts, and that might be therefore relevant, particularly in, say, primary bone repair, but perhaps not so much in the secondary bone repair. But the key thing is that clearly we need to control the infection, therefore we need to give the antibiotics, but is just to be aware that if we give very high doses for a long period of time is just to keep an eye on our fracture repair process in case there's inhibition of that by the treatment we're giving.
HAMISH SIMPSON: The next question I think we need to ask ourselves is whether our construct that we've got we have on there will stabilize the fracture to union. And you can see in this case here, there has already begun to be some loosening of the implant and it's unlikely that this will stabilize to unions. So with this infection here, it was better to intervene at this stage
HAMISH SIMPSON: and actually, we chose to put on a longer plate and do a Mascoli technique for this one rather than wait for this to, to fail. But if the construct will stabilize the fracture to union, then it may be possible to carry out either just, either just to suppress the infection or to carry out a DAIR procedure. So in terms of the revision procedures for FRI, I think just a few kind of principles.
HAMISH SIMPSON: One is that it's clear that we need to obtain stable fixation because that helps control the infection. There's work from several kinds of studies, particularly in models from in rabbits and hamsters showing that if you've got instability, it's very difficult for the body to control infection, whereas if you have stability, it's a lot easier to control infection. The second principle I'd suggest is that we don't contaminate an uncontaminated canal.
HAMISH SIMPSON: If the initial treatment has been with intramedullary nailing the canal is compromised and if you put a further intramedullary nail down, I don't think it is actually a problem. But if it hasn't been, if it's been a plate fixation, then I certainly prefer not to actually put a nail down to spread infection up and down the canal. And the other things, principle would be to minimize hardware, the hardware at the site of infection and to cover with local antibiotics.
HAMISH SIMPSON: So next thing is in terms of our union and find things, can we achieve union? And this depends, I think, on which strategy that we're going for and it's just to remind you that with fracture related infection, there's two interrelated orthopedic problems. One is deep bone infection and the other is a failure of fracture healing.
HAMISH SIMPSON: And the strategies you can either go for are to treat the fracture, then infection. Next one is to, first of all, treat the infection definitively and then the fracture, then to do both at the same time, which you would do if you were doing an acute shortening procedure. And finally, to do neither, which is to carry out an amputation, which again, as Neil has pointed out, happens in about 3% of the FRI cases. If possible, though, I suggest that you go for (a) which is to try and treat the fracture first and then the infection
HAMISH SIMPSON: because if you can get union, it is a lot, you can often carry out a less morbid procedure for the patient than if you actually kind of try if you go for these other options. So can union be obtained or even can union of part of the fracture be obtained? Because if you can achieve union of the articular component of a fracture, that can often again reduce the morbidity that's needed for the review of your option for final treatment.
HAMISH SIMPSON: In terms of whether you can, a DAIR procedure is likely to be successful. The smoking is one of the main things that reduces the chance of success. Smoking in general kind of reduces the chance of getting a union, but these colleagues in by Ritemire et al in 2008 pointed out it was a 3.7 times rate of failure if patients were smokers.
HAMISH SIMPSON: But the key thing, I think, is to monitor regularly and actually kind of deeper allude to this as well, that for us the CT scan is extremely useful for monitoring whether or not the healing is progressing, and we'll often have 6 to eight weeks get CT scans rather than plain films for monitoring whether or not the bone is healing. And this was just to show you this case, I showed you earlier on.
HAMISH SIMPSON: In fact, we chose not to intervene. We just put the person into a sarmienta cast, gave them some oral flucloxacillin until the actual bone had united, removed the metal work and then actually just reamed out the canal and the person need no needed, no further treatment. So a minimum kind of morbid morbidity process that compared to a wide excision at the site. In terms of trying to predict, though, whether or not this will work.
HAMISH SIMPSON: This is some work from that we wrote up with Jerry Tsang and others in terms of looking at whether or not there was a periosteal reaction at the fracture site. And in this case, there's no periosteal reaction, but here you become to see there is a periosteal reaction. And if there is a periosteal reaction, there's a far greater chance that with an exchange nailing procedure, the patients will go on to unite
HAMISH SIMPSON: so a five times relative risk of failure in accepting non unions if there is no periosteal reaction. So finally, when should we intervene surgically? This was just showing for this type of case, though, which achieves all of these five questions. The skin cover is inadequate, the position isn't adequate. I think you wouldn't want to accept this kind of position up here.
HAMISH SIMPSON: The infection kind of is not possible to control and the, we're not going to be able to hold this position to unions. So with all of these, this person was actually kind of treated, I think, very appropriately with a wide excision here and a switch to a frame to actually kind of obtain union. So in just two slides can conclude with. To me, in terms of when we should intervene surgically, I think there's five questions to ask
HAMISH SIMPSON: and if the answer to any of these is yes, is no at any time, then we should intervene. So first of all, skin. Is there adequate skin cover? Position. Is that satisfactory? Infection. Can it be suppressed to union and construct; will that hold the kind of bone to union and can union be obtained without further intervention. In terms of the principles, I think the skin; just the only thing is to remember the possibilities of acute and gradual shortening, particularly if the skin defect is less than your bone defect.
HAMISH SIMPSON: The position. I think it's frequently, it's possible to correct the shortening post union, but only occasionally do we correct alignment post union. If you can get your bone kind of healed in a good alignment, but just short, it's a relatively simple procedure then to regain length. Infection. Infection versus antibiotics is just to be aware of these conflicting things. It's clearly vitally important to control the infection
HAMISH SIMPSON: therefore, I, we will be using antibiotics, but just to be aware and to monitor whether or not they could be inhibiting the healing. And as I mentioned, local antibiotics, particularly useful and can titrate the bead size for the time that you want your dead space filler to be present. And in terms of the principle for if you've got to change your construct is just not contaminate an unadulterated canal.
HAMISH SIMPSON: And finally, if possible, go for union first strategy but to monitor very carefully with CT to see whether or not you're going to be able to achieve that. And I'll with that, I'll close. Thank you very much for your attention.
BILAL JAMAL: Hamish, that was, as ever, a phenomenal talk. In particular, thank you for the clarity of thought to there. One of the things that I wanted to clarify was around timing of surgery in that I suppose this group of patients presents in one of two fashions. There's a group of patients who present to clinic, for example, and they've had grumbling infection and problems consequent upon that, and they can be added to a semi-elective list, as it were.
BILAL JAMAL: But there's another group of patients who present in an urgent fashion and are admitted. What do you think the time frames should be for these group of patients having their surgery and who should do it and when should they be temporised with antibiotics till the situation settled down. So I'd just like to explore timings around surgery and a bit more detail, if you don't mind.
HAMISH SIMPSON: In terms of the question of who it should be done by I mean, I think all of these are consultant cases. I mean, they're not. a lot of them are very difficult decisions
HAMISH SIMPSON: so they should be consultant cases. In terms of the timing, I mean, I think one of the things is if you've got there's an acute inflammatory process going through the cellulitis, then it may well be that they can just be admitted for antibiotics and you don't actually have to intervene surgically for those ones. We will get an ultrasound, possibly an MRI but as Deepa's mentioned, the problem with MRI, if there's a lot of metalwork in there, it often can't actually tell you whether or not there's this pus that needs draining.
HAMISH SIMPSON: If there's pus that needs draining, then we will take them to theater for that. But if it's just a cellulolytic thing, we will just give antibiotics and then it comes back to the question, I think can we suppress the infection to union or do we need to intervene to get union? So it comes back to me those five questions rather than actually say that we have to go in and we have to change because if you do go in early, you will often end up doing a very wide resection.
HAMISH SIMPSON: You're then committing the person to potentially a bone transport procedure and months of treatment. So that's why, if at all possible, I'll go for the union first strategy. I'll try to avoid doing kind of a radical procedure, but at the same time monitoring very carefully and if we've got, if we're stagnation of healing, then you must intervene.
BILAL JAMAL: So thank you. That's really useful. I wanted to just add a couple of things before we finish up for the evening, the first of which was to again, thank our corporate supporters without whom this webinar series wouldn't be feasible. And there's Dr. Richard.
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