الفهرس 
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Abstract
Inflammation, bone formation, and bone remodelling are the three interconnected phases of the bone healing process. complications of bone healing include infection, delayed union, nonunion, malunion and growth abnormalities.
Without medical treatment, damaged bones often fail to mend properly, a condition known as nonunion. When medical imaging tests (such as x-rays or CT scans) show no improvement after 6-9 months, a diagnosis might be established.Nonunion may be due to infection, avascular necrosis, soft tissue interposition, poor fixation or due to the fracture pattern (increase with segmental fracture). nonunion may be septic or aseptic (atrophic, hypertrophic or oligotrophic). Numerous studies suggest that delayed union or non-union occurs in 5-10% of all long bone fractures.
When we talk about an infected fracture, we’re referring to an acute type of insult that occurs shortly after surgery or shortly after the injury has occurred. This means that the patient has had an open injury or sometimes a closed injury that has undergone surgery, and the wound has become contaminated and become red, hot, swollen, with some drainage and colonised with some type of bacteria.
Discharging sinus, pretreatment radiographs indicative of bone infection, and high serum markers of infection (ESR, CRP) all point to a diagnosis of infection. Different from infected fractures, which happen suddenly, infected nonunions are the result of a sub-acute infection in the bone or surrounding the site that prevents the bone from mending after a prior fracture.
Higher rates of recurrence and reoperation are seen in cases with infected nonunion treated with systemic antibiotics alone, without the use of local antibiotic delivery devices. As a result, medical-grade CS was developed and implemented; this material promotes osteoconductive osseous healing by filling the bone void and discouraging the ingrowth of fibrous tissue; as the CS is absorbed, fibro vascular tissue takes its place, allowing for neovascularization and bone formation. In addition, CS is compatible with a wide variety of antibiotics, and the combination’s slow dissolution allows for a prolonged release of medicines over time.
Therefore, this study was conducted to assess the role of CS loaded by antibiotics in eradication of infection, healing of fracture, and obtaining optimal restitution of the function.
This prospective study included twenty-four patients at any age and of any sex with infected non united fracture of long or short bones. The patients underwent the clinical evaluation of wound, sinuses, deformity, shortening as well as radiological assessment for evaluation of fracture healing through CT scan and MRI in addition to the routine laboratory assessment. All patients underwent debridement, intra operative cultures and sensitivity was made, the wound was explored through the pre-existing scar.
Summary of our Results:
• The original nature of fracture was simple in 10 (41.67%) patients, compound GI in 7 (29.17%) patients, compound GII in 2 (8.33%) patients and Compound GIII in 5 (20.83%) patients.
• Method of 1ry fixation was platting in 9 (37.5%) patients, interlocking nail in 2 (8.33%), hocked plate in 2 (8.33%) patients, external fixator in 3 (12.5%), external fixator and ender in 2 (8.33%) patients, ender in 5 (20.83%) patients and distal tibia plate in 1 (4.17%) patient.
• Presentation of infected nonunion was 3weeks postoperative in 2 (8.33%), 3months post operative in7 (29.17%) patients, 5months postoperative in 2 (8.33%) patients,6 months postoperative in 8 (33.33%) patients and 7months postoperative in 5 (20.83%) patients. The nature of infective nonunion was infected active draining in 12 (50%) patients, infected active non draining in 8 (33.33%) patients and infected quiescent non draining in 4 (16.67%) patients.
• Risk factors for developing infection and non-union, anemia was present in 6 (25%) patients, smoking in 12 (50%) patients, old age in 3 (12.5%) patients, DM in 4 (16.67%) patients, obesity in 2 (8.33%) and no recognizable risk factors were present in 6 (25%) patients.
• Hardware replacement was present in 10 (41.67%) patients.
• Bone gap or defect was less than 1cm in 15(62.5%) patients, about 2cm in 6 (25%) patients and more than 2cm in 3 (12.5%) patients. The use of bone graft was in 2 (8.33%) patients.
• As regards intraoperative culture, Coagulase -ve staph aureus was present in 3 (12.5%) patients, gram negative bacilli in 2 (8.33%) patients, pseudomonas aeruginosa in 5 (20.83%) patients, staph aureus (MRSA) in 9 (37.5%) patients, Staph aureus (MSSA) in 2 (8.33%) patients, streptococcus pyogenes in 1 (4.17%) patient and mixed infection in 2 (8.33%) patients.
• Regarding the disappearance of AICS beads, there were 10 (41.66%) patients within 30 days and 14 (58.33%) patients within 45 days. wound healing was good in 19 (79.17%) patients, superficial infection and ulceration in 2 (8.33%) patients and superficial infection in 3 (12.5%) patients. Regarding complete fracture union, no healing after 12months was in 2 (8.33%) patients, within 10 months in 3 (12.5%) patients, within 12 months in 2 (8.33%) patients, within 6months in 5 (20.83%) patients, within 6months then plate removal in 5 (20.83%) patients and within 9months in 7 (29.17%) patients
• OMAS was excellent in 9 (56.25%) patients, good in 6 (37.5%) patients and fair in 1 (6.25%) patient. Ten patients (62.5%) had an outstanding ASAMi score, while six patients (37.5%) had a good score. The patients that received the highest on the modified mayo wrist score were six (75%) and one (12.5%).
• Infection recurrence was not present in 20 (83.33%) patients, Superficial skin infection and deep infection in 2 (8.33%) patients.
• Postoperative complications were not present in 17 (70.83%) patients, wound infection treated with vac in 2 (8.33%) patients, limitation of knee movement in 3 (12.5%) patients and recurrence of infection treated with plate removal in 3 (12.5%) patients
• Shortening or deformity was about 1cm shortening in 2 (8.33%) patient.
We present evidence that the use of antibiotic-impregnated calcium sulphate pellets holds promise for treatment of infected nonunion of bone fracture, It offers the advantage of complete union within nine months and sparing patients the complications with no recurrence in most cases.
Here, we provide data from a group of twenty-four patients with infected nonunited or delayed united fractures of long and short bones treated with antibiotics impregnated CS (AICS).
Our research revealed both a high percentage of unions and the complete absence of infection.
Based on our findings, more research into the efficacy of antibiotic-impregnated CS (AICS) in the treatment of various illnesses is warranted.
Study recommendation:
Surgical debridement and local CS loaded with antibiotics is effective in management of infected nonunited or delayed united fracture of long or short bones after:
1) Control of risk factors of nonunion e.g. DM, smoking, anemia
2) Good stabilization of fracture
3) Good vascularity to fracture site
Careful monitoring of patients is advised since this treatment is both expensive and technically demanding.
Our findings show that this method reduces the risk of complications and speeds up the patient’s recovery so that they may go back to their regular routine as soon as possible.
Limitations
The number of participants in the study was minimal.
It was a single center study, and the results may differ elsewhere.
The study did not include a control group.
The study lacked the radiological and inflammatory markers assessment.
Recommendations
• Treatment of infected nonunion of bone fracture using antibiotic-impregnated calcium sulphate pellets is being evaluated as a viable option.
• Our findings are dependent on the outcomes of future multi-centric investigations with higher sample sizes.
• Measuring the inflammatory markers is essential to evaluate effectiveness of antibiotic-impregnated calcium sulphate pellets treatment in cases with infected nonunion fracture.