Treatment of Complex Infected Non-union of Bone of the Upper Extremity by a Staged Approach: Debridement and Antibiotic Cement Followed by a Vascularized Free Fibula Flap

Background: Infected non-union of bone of the upper extremity remains a difficult problem to treat with limited options. Management must address chronic osteomyelitis and skeletal instability caused by the non-union. We present our experience with a staged approach in five patients. Methods: The study cohort consisted of five males with an average age of 38 years and 4 prior procedures for infected non-union of the humerus (1) radius(1), ulna(1), ulna and radius(1) and metacarpal(1). The first stage consisted of aggressive debridement of all infected devitalized bone, bone cultures, removal of hardware, placement of antibiotic impregnated cement and stabilization with an external fixator (4 of 5 patients) followed by culture specific antibiotics. This was followed by definitive reconstruction using a free vascularized fibular flap and a course of post-operative antibiotics. Results: The average bony defect measured 8.6 cm. All flaps survived, one required re-exploration for venous thrombosis 72 hrs post-operatively and was successfully salvaged with a re-do anastomosis using a vein graft. The average time to bony union was 14 weeks. There was one hypertrophic non-union from proximal hardware failure which required repeat surgical intervention. At an average of 5.1 years follow-up all patients remain infection free and were working. Conclusions: A stage approach to the treatment of infected non-union of bone consisting of aggressive debridement, antibiotic cement, culture specific antibiotic followed by a vascularized fibular transfer is an effective treatment to a complex problem with limited alternatives. Keywords: Infected non-union of bone, Osteomyelitis, Microsurgery, Antibiotic cement, Free vascularized fibula flap.