Single-Stage Surgical Treatment of Infected Nonunion of the Distal Tibia

Objective: An infected nonunion of the distal tibia after plating is uncommon, and the traditional methods for its treatment have unique disadvantages (time-consuming and patient discomfort being great). A single-stage surgical technique was developed to improve the outcome in this situation. Design: Retrospective. Setting: University hospital. Patients and Methods: We treated 25 consecutive adult patients with 25 infected nonunions of the distal tibia after plating. The inclusion criteria consisted of infected nonunions of the distal tibia with an intact ankle space and a plate in situ. The surgical technique used with all participants called for the removal of all implants, intra-/extramedullary debridement, and placement of cancellous bone graft and antibiotics (vancomycin and gentamicin) followed by the application of an Ilizarov external fixator. Postoperatively, patients ambulated early with protected weightbearing and performed range-of-motion exercises of the ankle. Results: Twenty-two patients were followed up for at least 2 years (range, 2.0-4.5 years; median, 3.2 years). All infected nonunions healed without recurrence of infection. The median time to union was 4.5 months (range, 3.5-6.0 months). Eighteen cultures had single bacterial flora, whereas five cultures had mixed flora. Two cultures showed no growth of microorganisms. All bacteria were sensitive to vancomycin or gentamicin. Methicillin-resistant Staphylococcus aureus (13 of 25) and methicillin-sensitive S. aureus (seven of 25) were the most commonly detected microorganisms. Patients' ankle function improved with "satisfactory'' grades increasing from 0% preoperatively to 86% postoperatively (P < 0.001). Conclusions: This single-stage surgical technique had a high success rate with significant reduction in patient discomfort during the course of treatment. However, further revision of the technique may be necessary to ensure high success rates in further series.