Management of infected tibial plate osteosynthesis using a staging system for infected fractures

Osteomyelitis following plate osteosynthesis of a tibial shaft fracture was managed in 23 patients through a staging system and prospective treatment protocol. The staging system, which is arranged in an upstaging disease progression and downstaging treatment protocol, is composed of the status of osseous continuity (Type I to II) and the dead space created by the debridement surgery (Classes A to D). The follow-up period ranged from 20 to 48 months (average, 31.5 months). Staphylococcus aureus (35.5%) and Pseudomonas aeruginosa (29%) were the most commonly involved organisms. Twenty-two infections were initially arrested by one debridement, and one infection was arrested by three sequential debridements. There were seven Stage IA, one Stage IB, seven Stage IIA, two Stage IIB, three Stage IIC, and three Stage IID fractures in this study. The average number of surgical procedures were 1, 2, 2.1, 4, 4.7 and 6, respectively. The difficulty of treatment increased with the severity of the disease. The average time to bone union for Stage IIA, IIB, IIC and IID fractures were 11, 9, 20.3 and 21.5 months, respectively. A tibial osseous defect longer than 4 cm is a major prognostic factor for prolonged disability time. Important complications were nonunion one, bone graft stress fractures (two), and recurrence (three).