Article

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: 1.01). 05/2012; 7(1):20. DOI: 10.1186/1749-799X-7-20
Source: PubMed

ABSTRACT BACKGROUND: 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. METHODS: 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. RESULTS: 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/ul) 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 speciesspecific sequences enabled the identification of specific microorganisms (1x Methylobacterium species, 1x Staphylococcus species). Both PCR-positive patients were culture-negative. CONCLUSIONS: 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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    ABSTRACT: OBJECTIVE:: To review the results of a single stage treatment protocol for presumptive aseptic diaphyseal nonunion with a well healed wound and no infection history. DESIGN:: Retrospective comparative study SETTING:: Tertiary referral center PATIENTS AND METHODS:: We retrospectively reviewed all presumptive aseptic diaphyseal nonunions treated by this single stage treatment. There were 104 patients who met the inclusion criteria. Eighty-seven patients were available for follow-up through to complete healing (83.7% follow-up rate). INTERVENTION:: The protocol entails withholding preoperative antibiotics, implant removal, debridement or canal reaming, five cultures of the nonunion or reamings, followed by antibiotic administration and revision open reduction and internal fixation or exchange nailing. If intra-operative cultures are positive, long-term antibiotics are begun specific to organism sensitivities. MAIN OUTCOME MEASUREMENTS:: To analyze the rate of positive cultures and to compare the rate of secondary surgery to promote healing in positive and negative culture groups. RESULTS:: Intraoperative cultures were positive in 28.7% (25/87) of patients with complete follow-up. The overall rate of secondary surgery for persistence of nonunion was 12.6% (11/87). In patients with positive intraoperative cultures, rate of secondary surgery was 28% (7/25) versus 6.4% (4 /62) in the group without positive intraoperative cultures (p=0.01, Fischer's exact test). CONCLUSION:: A single stage treatment protocol for presumptive aseptic diaphyseal nonunions was effective in obviating further revision surgery in 93.6% of truly aseptic cases and in 72% of positive culture cases and is still employed at our institution. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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