The treatment of infected pseudoarthrosis of the upper limb with the fibular microvascular graft compared with the Ilizarov technique.

> Relazione

1.
Relazione tenuta al congresso europeo della chirurgia dell’arto superiore. (Lisbona 2003)

2.
Cortina is not only turist station (this is the Putti Institut)

3.
We have been treating the bone infections in Putti Institut of Cortina since 1930.

4.
We use for all patients the immuno stimulation with ITBS, this is a pool of inactive
stafilococcus and we observed many activities, that you can read hier.
It is like vaccine-therapy.

5.
One exemple of pandiaphysite of ulna in a young boy, at right the result after only two cycles of ITBS.

6.
The Ilizarov system is already known from some time. The tables of bone transfiction of the k-wires.

7.
In the Humerus we use a hybrid system of rings and k-wires with fiches. This is an example: assembling of forearm with compactotomy and distraction.

8.
X-ray at the patient arrival (infected pseudoarthrosis of radius with shortering of approximately 4 cm.).

9.
Application of system with compactotomy and distraction.

10.

Contact between stumps of pseudoarthrosis and formation of regenerated bone after approximately 2 months.

11.
Result when consolidated, that is to say after 4 more months.

12.

In our experience, the limit of compression, in one step, is 3 cm. Step by step we can arrive, for the upper limb, to 5 cm. Exceeding we have vascular problems to the distal part

13.

We modified the surgery treatement in bone infections with large bone loss. We do before the “maniacal” surgical debridement and after we apply the spacer of cement with antibiotics. In the second stage (after 45 – 60 days) if the laboratory, clinic and x ray are silent for the infection, we use the fibula microsurgery transfer. But why the spacer? Already since 1983 the defence capacity of staphylococcus, that prevents the action of antibiotics as general treatement, has been revealed. At the right the scheme of glycocalyx formation.

14.
…and it is from a lot of time that we have sought a local therapy at the beginning with the use of gentamycine beads to slow elimination. At the beginning as filler of cleaned space.

15.
…and then as real prosthesis of self made cement.

16.
In the picture we show the experimental study made to find out the best combination of cement and antibiotic. After we put both in colture with staphylococcus, and we see where it grows less.

17.
The self-made composition of cement and antibiotic that we use
Vancocin …..10%
Imipenem+cilastatina…5%
Cephalosporin of third generation …5%
The percentage depends on the quantity of cement powder:
For exemple: in to 40 gr. of cement powder we put 4 gr. of vancomicin, 2 gr. of cefotaxime and 2 gr. of imipem.

II A

18.
Recently we use prepared cement with antibiotic already pre-manufactured, such
as “coppal”, which contains gentamycine and clyndamicine we see their field of action. Those cements proved to be more resistant.

The requisite of the antibiotics to be mixed to the cement:
- Stable to the heat
- Soluble in water
- Available in powder
- Non toxic

Functions of cement spacer with antibiotic:
- Mechanical function
-It keeps the correct length
- Biological function
-It contributes to the recovery of the septic focus, maintaining high the local concentration of antibiotic.

II Bl

19.
Preparation in the operating room. But why in two stages?

20.
…because even if we made a good debridement with blue of methylene (vital stain)…

21.
…we had many focus relighting also after a long time, despite we were sure of a good debridement. An example of infection of microsurgical fibula transfer after debridement in one stage without spacer. .

22.
The fibula microvascular graft is a useful doner Picture that shows the anatomy of doner site, the skin incision and the vassels

23.
The arterial suture of fibula pedicule. In the homerus we prefer end to side and for the forearm end to end. This is the fibula pedicule in the middle of radial artery. (immagine tratta dal libro di Gilbert – Wood sul perone vascolarizzato).

24.
Another use of fibula with his vascularization is the following: young girl, open fracture, debridement, spacer with antibiotic, this is X-ray result before the operation of fibula transfer.

25.
Intraoperatory pictures showing the fibula cutting preserving the vascularization to reconstruct the homeral distal part.

26.
The synthesis and the X-ray result post - operation.

27.
The different local changes of fibula, the example of ulna. The hipertrhophia is different in the two parts (distal and proximal part).

28.
You can see in 3D the complete integration of the fibula in the ulna.

29.
Open fracture of right homerus.

30.
After 8 moths infected pseudoarthrosis 2 spacers, two months each, because infection persisted.

31.
After 4 months fibula microvascular graft (12 cm).

32.
X-ray control after 10 months and …

33.
…clinical control.

34.
Another example, a man with open fracture before he made the iliac bone graft without vascularization, wich was reabsorbed. In the lower part you can see the fistolography.

35.
Debridement… external fixator and spacer with antibiotic.

36.
After one month fibula microvascular graft. In the lower part you can see the X-ray control after removal of fixator approximately 4 months from the operation, with arthrodesis of the wrist.

37.
Clinical result.

38.
We used the classification of Weber and Cech of 1989, where we can see that in the fibula we had the cases with a wide loss of substance.

39.
The bacteries are the same for the Ilizarov and fibula treatment.

40.
For young people we use the fibula, because
the old age is a controindication, together
with smoke and diabetic disease.

41.
The localization.

42.
The associated operations. For the fibula we always use the spacer. They are 18 because in two cases we made it twice Now we try to use the Ilizarov method only for compression and the fibula where there is a wide loss of substance.

43.
The healing time is the same between 2 methods…

44.
…but considering the wide loss of substance filled with the fibula.

45.
The complications. In 2 cases of non resolution of pseudoarthrosis we used bone graft without vascu1arization because there was no infection. In the case of non resolution of infection, we removed the sequestreted fibula and proceaded with the llizarov. A problem is the reduction of the prono-supination also with the muscle limb between the bones of the forearm. I think because the infection strikes the interosseus membrane. No problem on the ankle of doner site.

46.
The conclusive parameters are not very different between the methods.

47.
To conclude: in the treatment of infected upper limb we try to use the fibula microvascular graft (the best microvascular doner site for the upper limb) with wide loss of substance, and the Ilizarov method for compression (maximum 5 cm., because, exceeding, we have vascular and functional problems). The time of operation is for the fibula 5/7 hours (one equipe with a good training); for the Ilizarov 3/4 hours. At the beginning we often make a debridement and apply the spacer with 2-3 antibiotics for, at least, 45 - 60 days. We repeat the treatment if there are signs of infection. The two stages method reduced the relighting of septic focus of 60 %. With this method we can remove a smaller part of bone leaving a smaller gap to recostruct.

48.
In case of infection in the distal part of ulna, we make, if possible, a Sauvé-Kapandji, if not, we remove the total distal part of ulna. One example. Debridement, spacer and arthrodesis of the radio-ulnar distal part.

49.
Thank you for your attention.

Dr. Ferdinando Da Rin
Istituti Codivilla-Putti
Cortina d’Ampezzo (BL)
Tel. (0436) 883111
a-mail: darin.ferdinando@iol.it