Tibial Fractures: Complications and Treatment Options

Tibial fracture

Hello Doctor: My brother is a patient with a closed fracture of the upper end of the right tibia and has undergone internal fixation surgery with bone screws.
One and a half months after discharge, he was diagnosed with acute hematogenous osteomyelitis of the tibia and was readmitted for debridement and suturing surgery, followed by antibiotic treatment before discharge.
About two months after discharge, he was diagnosed with chronic osteomyelitis and is required to take three antibiotics, with the possibility of removing the steel plate and screws from the tibia and undergoing debridement surgery.
I would like to ask the doctor:
1.
If he undergoes the removal of the steel plate and screws along with debridement surgery, is it more appropriate for the original surgeon who placed the artificial screws and plate to perform the operation, or is it acceptable for a surgeon from another hospital to do it? What are the pros and cons of each option?
2.
Is hyperbaric oxygen therapy effective in treating chronic osteomyelitis?
3.
What kind of examinations can determine if bacteria are hiding in the artificial bone plate and screws, as the doctor mentioned that a third surgery is necessary? I am concerned whether the third surgery is truly necessary.

4.
Is it necessary to remove the artificial steel plate and screws from the tibia after the bone has healed?
Thank you for your answers, Doctor.

Xiao Ting, 40~49 year old female. Ask Date: 2019/08/09

Dr. Chen Yongxue reply Orthopedics

1.
Is it more suitable for the original surgeon who initially placed the artificial plates and screws to perform the removal and debridement surgery, or is it acceptable for a surgeon from another hospital to do it? What are the pros and cons of each? Having the original surgeon perform the surgery is beneficial as they are more familiar with the patient's initial condition.
However, patients and their families often lose confidence and patience when faced with the diagnosis of osteomyelitis.
Every orthopedic surgeon has the opportunity to encounter osteomyelitis cases, so I recommend having the original surgeon perform the procedure.
2.
Can hyperbaric oxygen therapy effectively treat chronic osteomyelitis? Hyperbaric oxygen therapy can be beneficial for osteomyelitis but is currently only considered an adjunctive treatment and cannot replace debridement surgery.
Additionally, it tends to be more expensive.
3.
What kind of tests can determine if bacteria are hiding in the artificial plates and screws, as the doctor has indicated a need for a third surgery? I am concerned that a third surgery may not be necessary.
When there are implanted materials, osteomyelitis is often difficult to control effectively.
If possible, removal is recommended.
The most direct method to check for bacteria during surgery is through bacterial cultures.
Treatment for osteomyelitis often requires multiple surgeries, primarily for debridement to reduce bacterial colonies in the wound.
Additionally, using high concentrations of local antibiotics during surgery can enhance the anti-inflammatory effect.
5.
Is it necessary to perform a removal surgery for the artificial plates and screws implanted in the tibia after the bone has healed? Artificial implants are not natural components of the human body, so it is advisable to remove them.
Thank you.

Reply Date: 2019/08/09

More Info

Tibial fractures, particularly those involving the upper end of the tibia, can lead to a variety of complications, including infection and delayed healing. In your brother's case, the development of acute hematogenous osteomyelitis following his initial surgery is a serious concern. This condition occurs when bacteria enter the bone, often through the bloodstream, leading to inflammation and infection. The subsequent diagnosis of chronic osteomyelitis indicates that the infection has persisted and may require more aggressive treatment.

1. Surgical Considerations: When it comes to the removal of the internal fixation devices (plates and screws), it is generally advisable for the original surgeon to perform the procedure if they are available. The original surgeon is already familiar with the specifics of the case, including the surgical technique used and the anatomy involved. This familiarity can lead to a more efficient and potentially safer operation. However, if the original surgeon is not available, a qualified orthopedic surgeon at the new facility should be able to perform the surgery competently. The main advantage of having the original surgeon operate is their familiarity with the case, while the disadvantage might be logistical issues such as scheduling or distance. A new surgeon may bring a fresh perspective but may not have the same level of familiarity with the original surgical site.

2. Hyperbaric Oxygen Therapy (HBOT): This treatment has been shown to be beneficial in cases of chronic osteomyelitis. HBOT involves breathing pure oxygen in a pressurized room or chamber, which can enhance oxygen delivery to tissues, promote healing, and help fight infection. Studies have indicated that HBOT can improve outcomes in patients with chronic infections, particularly when used in conjunction with other treatments. However, it is not a standalone treatment and should be part of a comprehensive management plan.

3. Diagnostic Testing for Infection: To determine if bacteria are present around the hardware, several diagnostic tests can be performed. These may include imaging studies such as X-rays, MRI, or CT scans to look for signs of infection or abscess formation. Additionally, laboratory tests, including blood cultures and inflammatory markers (like CRP and ESR), can provide information about the presence of infection. In some cases, a biopsy of the bone or surrounding tissue may be necessary to identify the specific bacteria involved.

4. Necessity of Hardware Removal: The decision to remove internal fixation devices after bone healing depends on several factors, including the presence of infection, the type of hardware used, and the patient's overall health. In many cases, if the bone has healed properly and there are no complications, the hardware may be left in place. However, if there is chronic infection or if the hardware is causing pain or discomfort, removal may be necessary.
In summary, your brother's situation is complex and requires careful management. It is crucial to work closely with his healthcare team to monitor his condition and determine the best course of action. Regular follow-ups and open communication with his orthopedic surgeon will be key to addressing any concerns and ensuring the best possible outcome.

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