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72
Fig. 5.6 Case 5.1,
X-rays at 1year
postoperatively, showing
good alignment and
strengthening regenerate
N. Vanaclocha et al.
Fig. 5.7 Case 5.2,
X-rays upon the
patient’s arrival to the
emergency room,
showing a comminute
fracture of the right
distal tibia
5 Management ofFracture-Related Infection inCritical Bone Defects
Fig. 5.8 Case 5.2,
X-ray on the rst
postoperative day after
tibial and bula fractures
reduction and plating
73
from intraoperative samples. Bone transport
was carried out over 6months without incidents,
but the docking site did not show radiographic
signs of bone union after 9months (Fig.5.11).
We applied the accordion maneuver, but the
nonunion at the docking site persisted, so we
nally performed an ankle arthrodesis with a
retrograde nail, augmented with a small amount
of bone autograft. Union was observed a year
after this last surgery, 6 years after the initial
trauma (Fig.5.12). At the last follow-up consul-
tation, 9years after the initial trauma, the patient
walked painlessly without aids and was
working.
74
Fig. 5.9 Case 5.2,
X-ray at 6months after
DAIR (debridement,
antibiotics, and implant
retention) and iliac crest
autograft. Notice the
multiple broken screws
N. Vanaclocha et al.
Fig. 5.10 Case 5.2,
X-ray on the rst
postoperative day after
sampling, debridement,
placement of
vancomycin- and
gentamycin-impregnated
calcium sulfate in the
defect, proximal tibial
corticotomy, and circular
external xator
implantation for bone
transport
5 Management ofFracture-Related Infection inCritical Bone Defects
Fig. 5.11 Case 5.2,
X-rays at 9months after
ending of the bone
transport activation
phase. The docking site
has not yet consolidated
75
76
N. Vanaclocha et al.
Fig. 5.12 Case 5.2, X-rays 1year after ankle arthrodesis
with a retrograde nail and a small amount of nonvascularizedbone autograft. The nonunion site has healed
Case 5.3
A 56-year-old female, an overweight smoker with
chronic obstructive pulmonary disease, was admitted due to a left tibial diaphyseal fracture after a
trafc accident (Fig.5.13). She was treated with
open reduction and internal xation (Fig. 5.14),
and quit smoking following her surgeon’s recommendations. At 2 weeks postoperatively, the
wound broke down, without exposing hardware,
bone, or tendons, so it was treated conservatively
with dressings and oral ciprooxacin. At 3months
postoperatively, there were X-ray signs of partial
consolidation, but the wound had worsened,
exposing the tibialis anterior tendon (Fig.5.15), so
the patient was referred to our institution.
Fig. 5.13 Case 5.3, X-rays upon the patient’s arrival to
the emergency room, showing a left tibial diaphyseal
fracture
We obtained samples, removed the hardware,
debrided thoroughly, lled the 8cm segmental
defect with a gentamicin- and vancomycinimpregnated PMMA spacer and implanted an
external xator (F4 R2 I4) (Fig. 5.16). The
patient was started on intravenous daptomycin
and piperacillin-tazobactam. After a week, we
had culture results (ampicillin-resistant
Klebsiella oxytoca) and the soft tissue conditions
had improved, so we removed the PMMA spacer
and reconstructed the bone defect with a free
osteoseptocutaneous bula ap (Fig. 5.17). At
2 weeks postoperatively, the patient’s wounds
had healed and she was discharged on oral ciprooxacin. At 6months postoperatively, there were
X-ray signs of union at the ends of the bula
ap. At the three-year follow-up, the patient
remained free of signs or symptoms of infection
and walked painlessly without aids (Figs.5.18
and 5.19).
5 Management ofFracture-Related Infection inCritical Bone Defects
Fig. 5.14 Case 5.3, X-rays on the rst postoperative day
after reduction and osteosynthesis of the left tibial
fracture
Fig. 5.16 Case 5.3, X-ray on the rst postoperative day
after sampling, debridement, antibiotic-loaded polymethylmethacrylate implantation, and external xation
77
Fig. 5.15 Case 5.3, clinical appearance of the wound at
3months postoperatively. The tibialis anterior tendon is
exposed
Fig. 5.17 Case 5.3, intraoperative picture showing the
free bula osteocutaneous ap
78
Fig. 5.18 Case 5.3, standing X-ray (anteroposterior
view) 2 years after bula ap transfer. Note the bula
ap’s hypertrophy
Fig. 5.19 Case 5.3, standing X-ray (lateral view of the
left ankle) 2years after bula ap transfer. The screws,
though excessively long, did not bother the patient so they
were not removed
N. Vanaclocha et al.
Conclusions
There is no gold standard for the treatment of
infected bone defects. The reconstructive strategy will depend on the patient (their comorbidities, compliance, and preferences), their defect
(location, size and shape, condition of surrounding soft tissues), and the team’s experience and
preferences.
Bone reconstruction techniques based on local
bone regeneration depend on native bone ends
for healing, so their outcomes will be better, the
better the state of the bone ends. They comprise
bone grafts and techniques based on osteogenesis
distraction (ASRL and bone transport).
The patients that most benet from bone autografts (in the context of Masquelet’s induced
membrane technique or not, with or without local
antibiotics) are those with small defects, a healthy
soft tissue envelope and good infection control.
The larger the defect that bone autografts are
used for, the higher the rate of resorption and
infection recurrence.
Distraction osteogenesis techniques allow
almost immediate loading, so they will be of
greatest value in the lower limb, where they will
enable early weight-bearing. Secondary procedures are the norm, not the exception (the most
common one is docking-site grafting). Acute
shortening manages simultaneously stability,
dead space, and the soft tissues, so it is especially
suitable for FRI patients with defects that will not
need re-lengthening. ASRL is a good option for
patients with infected bone defects up to 3–4cm
(some patients adapt to the specialized platform
shoe well and decline re-lengthening). Bone
transport is mostly used for infected bone defects
of the lower limb between 4 and 10cm, and is
especially useful in patients with bone deformities and malalignments.
Bone reconstruction techniques based on bone
replacement are bone aps. They have the shortest time to union and lowest complication rate
out of all the available techniques, at the cost of
donor-site morbidity and prolonged protected
5 Management ofFracture-Related Infection inCritical Bone Defects
79
axial load. The patients best beneted by bone
aps are those with vascular compromise of the
FRI site (e.g., previous unsuccessful attempts),
precarious soft tissue coverage (I3–4), an upper
limb defect, or a metaphyseal bone defect.
Additionally, the larger the defect, the stronger
the indication for a bone ap (there will be less
available techniques).
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Transfer ofVascularized Bone
inFracture-Related Infection
FernandoHolc, PedroBronenbergVictorica,
NievesVanaclocha
, andJorgeGuillermoBoretto
6
Introduction
Fracture-related infections (FRIs) are a major
challenge in orthopedic surgery. Their management is especially complex when they are associated with critical-size bone defects, that is, those
that do not heal without intervention [1, 2].
Several techniques are available to address
infected bone defects. The choice of surgical technique is based on several factors, including the
defect’s characteristics (location, size, and shape),
the condition of the surrounding soft tissues, the
patient’s comorbidities and treatment compliance,
as well as the surgeon’s experience and preferences [3–5]. For more information on technique
selection, refer to complementary Chap. 5.
One of the available techniques is bone aps.
In this chapter, we will focus on how bone aps
differ from other alternatives in FRI treatment,
which patients benet the most from them,
F. Holc · P. BronenbergVictorica · J. G. Boretto (*)
Hand and Upper Extremity Department, Instituto de
Ortopedia y Traumatología “Prof. Dr. Carlos
Ottolenghi”. Hospital Italiano de Buenos Aires,
Ciudad Autónoma de Buenos Aires, Argentina
e-mail: jorge.boretto@hospitalitaliano.org.ar
N. Vanaclocha
Orthoplastics Unit and Department of Plastic and
Reconstructive Surgery, University and Polytechnic
Hospital La Fe, Valencia, Spain
which bone aps are most frequently used in the
context of FRI, and what their possible complications are.
How Do Bone Flaps Dier
fromOther Alternatives inFRI
Treatment?
The techniques to address infected critical bone
defects can be broadly divided into two groups:
those based on local bone regeneration and those
based on bone replacement.
Techniques based on local bone regenera-
tion are faster and less invasive than bone aps
but rely on local bone and soft tissues (usually
scarred from the trauma and prolonged inammation) for healing. Thus, they have better outcomes,
the better the state of the local tissues. They
includenon-vascularized bone grafts (in the context of Masquelet’s induced membrane technique
or not, with or without antibiotics) and techniques
based on osteogenic distraction (acute shortening
and re-lengthening, and bone transport).
The patients that most benet from nonvascularizedbone autografts are those with small
defects with good soft tissue coverage and infection control (the larger the defect, the higher the
rate of resorption and infection recurrence).
Creeping substitution is slow and unreliable, so
results of bone grafting are unpredictable, and
regrafting is often necessary.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
N. Vanaclocha (ed.), Treatment of Fracture-Related Infection,
https://doi.org/10.1007/978-3-031-92452-1_6
81