Is non-union of tibial shaft fractures due to nonculturable bacterial pathogens? A clinical investigation using PCR and culture techniques

Journal of Orthopaedic Surgery and Research (Impact Factor: 1.39). 05/2012; 7(1):20. DOI: 10.1186/1749-799X-7-20
Source: PubMed


Non-union continues to be one of the orthopedist’s greatest challenges. Despite effective culture methods, the detection of low-grade infection in patients with non-union following tibial fracture still presents a challenge. We investigated whether “aseptic” tibial non-union can be the result of an unrecognized infection.

A total of 23 patients with non-union following tibial shaft fractures without clinical signs of infection were investigated. Intraoperative biopsy samples obtained from the non-union site were examined by means of routine culture methods and by polymerase chain reaction (PCR) for the detection of 16 S ribosomal RNA (rRNA). Control subjects included 12 patients with tibial shaft fractures.

23 patients (8 women and 15 men; mean age: 47.4 years) were included into this study. Preoperative C-reactive protein levels (mean: 20.8 mg/l) and WBC counts (mean: 8,359/μl) in the study group were not significantly higher than in the control group. None of the samples of non-union routine cultures yielded microorganism growth. Bacterial isolates were found by conventional culturing methods in only 1 case of an open fracture from the control group. In this case, PCR yielded negative results. 16 S rRNA was detected in tissue specimens from 2 patients (8.7%) with non-union. The analysis of these variable species-specific sequences enabled the identification of specific microorganisms (1x Methylobacterium species, 1x Staphylococcus species). Both PCR-positive patients were culture-negative.

The combination of microbiological culture and broad-range PCR seems to substantially add to the number of microbiological diagnoses obtained and may improve the clinican’s ability to tailor therapy to the individual patient’s needs.

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Available from: Arndt P. Schulz,
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    • "It appears that the classic concept of considering infection as causative factor [10], or even predictor of non-union [11], is transforming. There is strong evidence that an infection delays the fracture healing process by recruitment of granulocytes and macrophages [12], direct action of bacteria and/or their products to the callus [13], osteolysis evoked by pro-inflammatory cytokines [14], delaying fracture repair, as well as often compromising the stability of the fixation [15]. However, from common clinical experience, well summarised in the study of Rightmire et al. [16], infected fractures successfully suppressed with antibiotics can progress to union as long as the fixation is stable. "
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