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Alt V, McNally M, Wouthuyzen-Bakker M, Metsemakers WJ, Marais L, Zalavras C, Morgenstern M. The FRI classification - A new classification of fracture-related infections. Injury 2024; 55:111831. [PMID: 39259992 DOI: 10.1016/j.injury.2024.111831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/14/2024] [Accepted: 08/17/2024] [Indexed: 09/13/2024]
Abstract
AIM To identify the most relevant factors with respect to the management of fracture-related infection (FRI) and to develop a comprehensive FRI classification that guides decision-making and allows scientific comparison. METHOD An international group of FRI experts determined the preconditions, purpose, primary factors for inclusion, format and detailed description of the elements of an FRI classification through a consensus driven process. RESULTS Three major elements were identified and grouped together in the FRI Classification: Fracture (F), Related patient factors (R) and Impairment of soft tissues (I). Each element was divided into five levels of complexity. Fractures can be healed (F1) or unhealed (F2-5). Patients may be fully healthy (R1) or have 4 levels of compromise, with and without end-organ damage (R2-5). Soft tissue condition ranges from well vascularized and easily closed (I1) to major skin defects requiring free flaps (I4). In all three elements, the fifth level (F5, R5 or I5) describes a patient who has an unreconstructible bone, soft tissue envelope or is not fit for surgery. CONCLUSION The FRI classification, which is based on the three major elements Fracture (F), Related patient factors (R) and Impairment of soft tissues (I) is intended to guide decision-making and improve the quality of scientific reporting for FRIs in the future. The proposed classification is based on expert opinion and therefore an essential next step is clinical validation, in order to realize the ultimate goal of improving outcomes in the management of FRI.
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Affiliation(s)
- Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Leonard Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland
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de Francisco Jiménez Cortes D, Lamberti EMB. Femoral alloprosthesis in bone defect of 30 cm as extremity salvage. Trauma Case Rep 2024; 53:101082. [PMID: 39183809 PMCID: PMC11342872 DOI: 10.1016/j.tcr.2024.101082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2024] [Indexed: 08/27/2024] Open
Abstract
Defects in femoral bone segments represent a reconstructive challenge; they are caused secondary to multiple and extensive debridement in cases of patients with infections, tumors or high-energy trauma. Different treatments have been proposed to address this problem, however, these are limited when it comes to large defects that generate instability of the implants in the native bone as well as loss of functionality and length of the extremities. In the proximal femur, allograft prosthesis composites have been described in the management of extensive tumor resections, but they are not yet widely used in the management of bone defects due to osteomyelitis. The case of a 51-year-old male patient with post-traumatic pan-osteomyelitis of the femur Cierny-Mader IV with a 30-centimeter defect in whom limb salvage was achieved through the application of a femoral alloprosthesis is presented, exhibiting this surgical technique as an alternative in ample resections secondary to infectious processes in young patients, furthermore, offering a solution to the shortage of some prosthetic components in our surrounding.
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Huffman SS, Berger LE, Li K, Spoer DL, Gupta NJ, Truong BN, Akbari CM, Evans KK. Muscle versus Fascia Free Tissue Transfer for Treatment of Chronic Osteomyelitis in the Comorbid Population. J Reconstr Microsurg 2024; 40:253-261. [PMID: 37579781 DOI: 10.1055/a-2153-2285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. METHODS Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status. RESULTS Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n = 28) and 41.7% received muscle flaps (n = 20). The most common comorbidities included diabetes mellitus (n = 29, 60.4%), peripheral neuropathy (n = 27, 56.3%) and peripheral vascular disease (n = 24, 50.0%). Methicillin-resistant or methicillin -sensitive Staphylococcus aureus were the most common pathogen in 18.7% (n = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 (n = 38) and 83.3% (n = 40), respectively. The overall rate of microsurgical flap success was 93.8% (n = 45). Osteomyelitis recurred in 25% of patients (n = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, p = 0.973). CONCLUSION This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.
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Affiliation(s)
- Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Karen Li
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Nisha J Gupta
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Brian N Truong
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Nandanwar SP, Ramteke SU. A Holistic Approach for Physiotherapy Rehabilitation of Girdlestone Arthroplasty With Infection and Concomitant Contralateral Spastic Hemiplegic Cerebral Palsy: A Case Report. Cureus 2024; 16:e57689. [PMID: 38711685 PMCID: PMC11070613 DOI: 10.7759/cureus.57689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/05/2024] [Indexed: 05/08/2024] Open
Abstract
Girdlestone arthroplasty is a traditional approach for complicated infections occurring with contralateral spastic hemiplegic cerebral palsy, which presents intricate challenges in rehabilitation. In this case report, an 18-year-old girl came to a multispecialty hospital with a history of falls. She was an identified case of femoral head dislocation with acute osteomyelitis and a history of spastic hemiplegic cerebral palsy. She underwent girdlestone arthroplasty with additional upper tibial and ankle pin traction. After that, she was referred to physiotherapy management. To further aid recovery, rehabilitation protocol included a combination of static exercises, ankle pumps on the affected side, and stretching, bimanual hand-arm training with lower limb training on the unaffected side to reduce spasticity. Once the stitches were removed and traction discontinued, the focus shifted to improving mobility through basic activities like rolling and transitioning to sitting, gradually progressing to standing with the assistance of a walker and bimanual hand-arm training with lower limb training for spasticity. Outcome measures like functional independence measure, numerical pain rating scale, range of motion, and manual ability classification system were used to record patient progress during rehabilitation. This case report serves the crucial role physiotherapy plays in the treatment of orthopedic and neurological conditions in younger patients, with the ultimate goal of regaining functional independence and enhancing overall quality of life.
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Affiliation(s)
- Sojwal P Nandanwar
- Department of Sports Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swapnil U Ramteke
- Department of Sports Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Marais LC, Zalavras CG, Moriarty FT, Kühl R, Metsemakers WJ, Morgenstern M. The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention. J Orthop 2024; 50:36-41. [PMID: 38162257 PMCID: PMC10755499 DOI: 10.1016/j.jor.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
The aim of this narrative review is to describe the various surgical management strategies employed in fracture-related infection (FRI), to explore how they are selected and discuss the rationale for early surgical intervention. Surgical treatment options in patients with FRI include debridement, antibiotics and implant retention (DAIR), revision (exchange) or removal. In selecting a treatment strategy, a variety of factors need to be considered, including the condition of the bone, soft tissues, host and causative microorganism. Irrespective of the selected treatment strategy, prompt surgical intervention should be considered in order to confirm the diagnosis of an FRI, to identify the causative organism, remove necrotic or non-viable tissue that can serve as a nidus for ongoing infection, ensure a healthy soft tissue envelope and to prevent the vicious cycle of infection associated with skeletal and/or implant instability. Ultimately, the objective is to prevent the establishment of a persistent infection. Urgent surgery may be indicated in case of active, progressive disease with systemic deterioration, local progression of infection, deterioration of soft tissues, or progressive fracture instability. In case of static disease, the patient should be monitored closely and surgery can be performed on an elective basis, allowing adequate time for optimisation of the host through risk factor modification, optimisation of the soft tissues and careful planning of the surgery.
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Affiliation(s)
- Leonard C. Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Charalampos G. Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Fintan T. Moriarty
- AO Research Institute Davos, Davos, Switzerland
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Richard Kühl
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Hygiene, University Hospital Basel, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Arora S, Rai V, Tripathi D, Chaudhary SM, Singh A, Chowdary M. Osteomyelitis Masquerading as Cellulitis: A Case Report. Cureus 2024; 16:e53238. [PMID: 38425588 PMCID: PMC10903755 DOI: 10.7759/cureus.53238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Osteomyelitis, a significant global healthcare issue, often results from infections related to open fractures, surgery, or conditions like diabetic foot ulcers. This report describes a case of osteomyelitis in a 62-year-old female with various pre-existing health conditions. The patient initially presented with swelling, pain, and difficulty walking in the right lower extremity, accompanied by systemic symptoms. Despite an initial diagnosis of cellulitis and treatment with ceftriaxone, a subsequent CT scan revealed a pretibial abscess and confirmed osteomyelitis caused by pan-sensitive Escherichia coli. Surgical debridement was performed, and the patient received six weeks of intravenous antibiotics. Hence, a heightened level of suspicion is essential to facilitate a timely diagnosis of osteomyelitis and enhance long-term prognosis. The case underscores the importance of a multidisciplinary approach, including meticulous surgical intervention and tailored antimicrobial therapy, in achieving positive outcomes for osteomyelitis patients.
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Affiliation(s)
- Sanjiya Arora
- Internal Medicine, Sub-Divisional Hospital (SDH) cum Civil Hospital, Fatehabad, IND
| | - Vikramaditya Rai
- Orthopedics, Dr. Rajendra Prasad Government Medical College & Hospital, Kangra, IND
| | | | - Sachin M Chaudhary
- Internal Medicine, Gujarat Cancer Society (GCS) Medical College, Hospital and Research Centre, Ahmedabad, IND
| | - Ajay Singh
- Internal Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Mohitha Chowdary
- Internal Medicine, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, IND
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Marais LC, Hungerer S, Eckardt H, Zalavras C, Obremskey WT, Ramsden A, McNally MA, Morgenstern M, Metsemakers WJ. Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg 2024; 144:259-268. [PMID: 37921993 PMCID: PMC10774153 DOI: 10.1007/s00402-023-05073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/11/2023] [Indexed: 11/05/2023]
Abstract
A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.
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Affiliation(s)
- Leonard C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sven Hungerer
- Department of Joint Surgery and Arthroplasty, Trauma Center Murnau, Murnau Germany and Paracelsus Medical University (PMU) Salzburg, Salzburg, Austria
| | - Henrik Eckardt
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Ramsden
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Fähndrich C, Gemperli A, Baumberger M, Bechtiger M, Roth B, Schaefer DJ, Wettstein R, Scheel-Sailer A. Treatment approaches of stage III and IV pressure injury in people with spinal cord injury: A scoping review. J Spinal Cord Med 2023; 46:705-715. [PMID: 36129337 PMCID: PMC10446796 DOI: 10.1080/10790268.2022.2108645] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
CONTEXT The treatment of pressure injury (PI) stage III and IV in people with spinal cord injury or spinal cord disorder (SCI/D) requires a multidisciplinary and surgical involvement. OBJECTIVES This scoping review aims to identify published relevant surgical multidisciplinary treatment approaches, describe the elements and evaluate the effectiveness of the approaches. METHODS We searched PubMed and Medline databases for studies about treatment approaches for people aged ≥18 years with chronic SCI/D and PI stage III or IV over ischium, trochanter or sacrum published between January 1990 and December 2021 in English or German language. Two independent reviewers screened the articles. One reviewer extracted information on study author(s), year of publication, study title, study design, country of origin, sample size as well as data on elements and effectiveness of the approaches. RESULTS 10 different approaches were described in two retrospective cohort studies, three case series, five discussion papers, one review and one guideline. All approaches included debridement, flap surgery, pressure relief and immobilization as well as infection control. Some approaches described elements such as risk screening (7/10), osteomyelitis treatment (8/10), nutritional therapy (8/10), physiotherapy, occupational therapy and psychology (6/10), spasticity control (7/10), and prevention and education (6/10). Only one study reported on the effectiveness of the approaches. CONCLUSION There are key elements for surgical multidisciplinary treatment approaches. However, due to differences in the content of some of these elements and missing elements in some approaches, comparability is difficult and the effectiveness of the complex approaches remains uncertain.
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Affiliation(s)
- Carina Fähndrich
- Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Armin Gemperli
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
- Center of Primary and Community Care, University of Lucerne, Lucerne, Switzerland
| | | | - Marco Bechtiger
- Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Bianca Roth
- Department of Internal Medicine, Infectious Diseases Service, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Dirk J. Schaefer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
| | - Reto Wettstein
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
| | - Anke Scheel-Sailer
- Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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Langit MB, Tay KS, Al-Omar HK, Barlow G, Bates J, Chuo CB, Muir R, Sharma H. Surgical debridement in long bone chronic osteomyelitis: is wide tumour-like resection necessary? Bone Jt Open 2023; 4:643-651. [PMID: 37611921 PMCID: PMC10446974 DOI: 10.1302/2633-1462.48.bjo-2023-0017.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Aims The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit. Methods We analyzed the retrospective record review from 2014 to 2020 of patients with long bone COM. All were managed by multidisciplinary infection team (MDT) protocol. Adequate debridement was employed for all cases, and no case of wide resection was included. Results A total of 53 patients (54 bones) with median age of 45.5 years (interquartile range 31 to 55) and mean follow-up of 29 months (12 to 59) were included. In all, ten bones were Cierny-Mader type I, 39 were type III, and five were type IV. All patients were treated with single-staged management, except for one (planned two-stage stabilization). Positive microbial cultures grew in 75%. Overall, 46 cases (85%) had resolution of COM after index procedure, and 49 (90.7%) had resolution on last follow-up. Four patients (7%) underwent second surgical procedure and six patients (11%) had complications. Conclusion We challenge the need for wide tumour-like resection in all cases of COM. Through detailed preoperative evaluation and planning with MDT approach, adequate debridement and local delivery of high concentration of antibiotic appears to provide comparable outcomes versus radical debridement.
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Affiliation(s)
- Mickhael B. Langit
- Department of Orthopaedics, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Department of Orthopedics, Philippine Orthopedic Center, Quezon City, Philippines
| | - Kae S. Tay
- Department of Orthopaedics, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Hussain K. Al-Omar
- Department of Orthopaedics, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Gavin Barlow
- Department of Infectious Diseases, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Joanna Bates
- Department of Radiology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Cher B. Chuo
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ross Muir
- Department of Orthopaedics, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Hemant Sharma
- Department of Orthopaedics, Hull University Teaching Hospitals NHS Trust, Hull, UK
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Wijendra A, Ramsden A, McNally M. A natural history of untreated chronic osteomyelitis of the tibia over 20 years, with evolving squamous cell carcinoma: a case report. J Bone Jt Infect 2023; 8:183-188. [PMID: 37780529 PMCID: PMC10539787 DOI: 10.5194/jbji-8-183-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/07/2023] [Indexed: 10/03/2023] Open
Abstract
Squamous cell carcinoma (SCC) is a rare but potentially life-threatening complication of chronic osteomyelitis. Whilst there have been over 100 cases of chronic osteomyelitis with malignant transformation reported in the literature between 1999 and 2020, this is the first case report to document transformation with 20 years of concordant imaging and clinical review.
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Affiliation(s)
- Asanka Wijendra
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University
Hospitals, Windmill Road, Oxford, OX3 7HE, UK
| | - Alex Ramsden
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University
Hospitals, Windmill Road, Oxford, OX3 7HE, UK
| | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University
Hospitals, Windmill Road, Oxford, OX3 7HE, UK
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11
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Sliepen J, Hoekstra H, Onsea J, Bessems L, Depypere M, Noppe N, Herteleer M, Sermon A, Nijs S, Vranckx JJ, Metsemakers WJ. Treatment and outcome of fracture-related infection of the clavicle. Injury 2023; 54:110910. [PMID: 37421837 DOI: 10.1016/j.injury.2023.110910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. METHODS All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. RESULTS We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n = 6), free vascularized fibular graft (n = 5), cancellous bone graft (n = 1)) to reconstruct the bone defect. The median follow-up was 32.3 (P25-P75: 23.9-51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P25-P75: € 7.953-23.798) per patient. CONCLUSION FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. In our opinion, when treated adequately using a multidisciplinary patient-specific approach, the outcome of patients with an FRI of the clavicle is good. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Although not studied individually, we consider factors such as the size of the bone defect, condition of the soft tissue, and patient demand important when it comes to guiding our surgical decision making in cases of osseous defects.
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Affiliation(s)
- Jonathan Sliepen
- University Medical Center Groningen, Department of Trauma Surgery, University of Groningen, 9713 GZ Groningen, The Netherlands; University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Laura Bessems
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Melissa Depypere
- University Hospitals Leuven, Department of Laboratory Medicine, 3000 Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of Radiology, 3000 Leuven, Belgium
| | - Michiel Herteleer
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - An Sermon
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Stefaan Nijs
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Jan J Vranckx
- University Hospitals Leuven, Department of Plastic and Reconstructive Surgery, 3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium.
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Sambri A, Cevolani L, Passarino V, Bortoli M, Parisi SC, Fiore M, Campanacci L, Staals E, Donati DM, De Paolis M. Mid-Term Results of Single-Stage Surgery for Patients with Chronic Osteomyelitis Using Antibiotic-Loaded Resorbable PerOssal ® Beads. Microorganisms 2023; 11:1623. [PMID: 37512796 PMCID: PMC10385580 DOI: 10.3390/microorganisms11071623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
This retrospective study reports on the treatment of chronic osteomyelitis with local debridement combined with PerOssal®. The diagnosis of chronic osteomyelitis was confirmed in all cases and classified according to the Cierny-Mader (C-M) classification. The primary outcome was the eradication of infection at a minimum of one year after surgery. A total of 93 patients (median age: 40 years) were included. The most represented sites were the femur (24, 25.8%) and tibia (52, 55.9%). Twenty-six patients (28.0%) had significant local or systemic comorbidities (C-M Class B hosts). According to anatomic type, 31 cases were type I, 13 type II, 21 type III and 28 type IV. Vancomycin was added to PerOssal® in most cases (80, 86.0%). In 24 (25.8%) cases, Vancomycin and Rifampicin were combined. In 32 (34.4%) cases, intraoperative cultures were negative. Staphylococcus aureus was isolated in 39 (63.9%) patients, and Gram-negative bacteria were isolated in 12 cases. The median follow-up was 21 months (range 12-84). A total of 21 (22.6%) patients developed an infection recurrence (IR) after a median follow-up of 11 months (range: 1-47). PerOssal® holds several practical advantages compared to other bone void fillers. Thus, due to its good biocompatibility and sufficient antibiotic release, it represents a viable adjuvant treatment in chronic osteomyelitis.
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Affiliation(s)
- Andrea Sambri
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Cevolani
- Orthopedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Valentina Passarino
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marta Bortoli
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Stefania Claudia Parisi
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Michele Fiore
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Laura Campanacci
- Orthopedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Eric Staals
- Orthopedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Davide Maria Donati
- Orthopedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Massimiliano De Paolis
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Klim SM, Amerstorfer F, McNally MA, Trebse R, Slokar U, Sigmund IK, Hecker A, Reinbacher P, Leitner L, Bernhardt GA, Leithner A, Wanko S, Glehr M. The Sinus Tract in Bone and Joint Infection: Minimally Invasive Salvation or Prolonged Suffering? A Multicenter Study. J Pers Med 2023; 13:jpm13050737. [PMID: 37240906 DOI: 10.3390/jpm13050737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
This study assessed the quality of life (QOL) and the functional outcome in daily living in patients with a chronic, treatment-resistant periprosthetic joint infection (PJI) or osteomyelitis, living with a natural or iatrogenic sinus tract. METHODS A follow-up examination in three national reference centers for septic bone and joint surgery was performed utilizing the Hospital Anxiety and Depression Scale (HADS-D/A), the Visual Analogue Scale (VAS), and the Short Form-36 (SF-36) score, including patients with a chronic sinus tract due to treatment-resistant PJI or osteomyelitis. RESULTS In total, 48 patients were included, with a mean follow-up time of 43.1 ± 23.9 months. The mean SF-36 Mental Component Summary (MCS) was 50.2 (±12.3) and the Physical Component Summary (PCS) was 33.9 (±11.3). The mean HADS-D was 6.6 (±4.4) and HADS-A was 6.2 (±4.6), and the VAS was 3.4 (±2.6). The SF-36 MCS showed no significant differences between the study group and the standard population (47.0, p = 0.10), as well as the HADS-A. The PCS in the study population was significantly worse (50.0, p < 0.001), as was the HADS-D. CONCLUSIONS A sinus tract represents a treatment option in selected cases with an acceptable QOL. The treatment should be considered for multimorbid patients with a high perioperative risk or if the bone or soft tissue quality prevents surgery.
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Affiliation(s)
- Sebastian Martin Klim
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Florian Amerstorfer
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Martin A McNally
- The Bone Infection Unit, Oxford University Hospitals, Oxford OX3 7HE, UK
| | - Rihard Trebse
- Orthopaedic Hospital Valdoltra, 6280 Ankaran, Slovenia
| | - Urban Slokar
- Orthopaedic Hospital Valdoltra, 6280 Ankaran, Slovenia
| | - Irene Katharina Sigmund
- The Bone Infection Unit, Oxford University Hospitals, Oxford OX3 7HE, UK
- Department of Orthopaedics and Tramatology, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Andrzej Hecker
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Patrick Reinbacher
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | | | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Sophie Wanko
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Mathias Glehr
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
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Wang X, Zhang M, Zhu T, Wei Q, Liu G, Ding J. Flourishing Antibacterial Strategies for Osteomyelitis Therapy. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2206154. [PMID: 36717275 PMCID: PMC10104653 DOI: 10.1002/advs.202206154] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/05/2022] [Indexed: 06/18/2023]
Abstract
Osteomyelitis is a destructive disease of bone tissue caused by infection with pathogenic microorganisms. Because of the complex and long-term abnormal conditions, osteomyelitis is one of the refractory diseases in orthopedics. Currently, anti-infective therapy is the primary modality for osteomyelitis therapy in addition to thorough surgical debridement. However, bacterial resistance has gradually reduced the benefits of traditional antibiotics, and the development of advanced antibacterial agents has received growing attention. This review introduces the main targets of antibacterial agents for treating osteomyelitis, including bacterial cell wall, cell membrane, intracellular macromolecules, and bacterial energy metabolism, focuses on their mechanisms, and predicts prospects for clinical applications.
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Affiliation(s)
- Xukai Wang
- Department of Thoracic SurgeryChina‐Japan Union Hospital of Jilin University126 Xiantai StreetChangchun130033P. R. China
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied ChemistryChinese Academy of Sciences5625 Renmin StreetChangchun130022P. R. China
| | - Mingran Zhang
- Department of Thoracic SurgeryChina‐Japan Union Hospital of Jilin University126 Xiantai StreetChangchun130033P. R. China
| | - Tongtong Zhu
- Department of Thoracic SurgeryChina‐Japan Union Hospital of Jilin University126 Xiantai StreetChangchun130033P. R. China
| | - Qiuhua Wei
- Department of Disinfection and Infection ControlChinese PLA Center for Disease Control and Prevention20 Dongda StreetBeijing100071P. R. China
| | - Guangyao Liu
- Department of Thoracic SurgeryChina‐Japan Union Hospital of Jilin University126 Xiantai StreetChangchun130033P. R. China
| | - Jianxun Ding
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied ChemistryChinese Academy of Sciences5625 Renmin StreetChangchun130022P. R. China
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15
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Sweere V, Sliepen J, Haidari S, Depypere M, Mertens M, IJpma F, Metsemakers WJ, Govaert G. Use of negative pressure wound therapy in patients with fracture-related infection more than doubles the risk of recurrence. Injury 2022; 53:3938-3944. [PMID: 36424686 DOI: 10.1016/j.injury.2022.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/11/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Fracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery. Despite its widespread use, the role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI. The aim of this study was to assess the relationship between the application of NPWT and its duration and recurrence of infection in operatively treated FRI patients. PATIENTS AND METHODS This is a retrospective cohort study based on the FRI database of three level 1 Trauma Centres. Included patients had to be at least 16 years of age and surgically treated for FRI between January 1st 2015 and September 1st 2020. Patients were subdivided in either the NPWT group, when NPWT was applied as part of the FRI treatment, or in the control group, when no NPWT had been applied. To limit confounding, patients were excluded if they (also) underwent NPWT prior to the diagnosis of FRI. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model. RESULTS A total of 263 patients were included, 99 in the NPWT group and 164 in the control group. The median duration of NPWT was 18.0 (IQR 15.8) days. In the NPWT group, 28 patients (28.3%) developed a recurrent FRI. In the control group, 19 patients (11.6%) had a recurrent FRI (p = 0.001, 95% CI [0.174 - 0.635]). In the NPWT group there were no significant differences in baseline characteristics between the recurrence and non-recurrence group. The duration of NPWT was associated with a higher risk of recurrence of infection (p = 0.013, OR 1.036, 95% CI [1.008 - 1.066]). CONCLUSION Delayed wound closure with the application of NPWT increased the risk of recurrence of infection in patients with soft tissue defects after FRI treatment. Therefore, it is advised to consider NPWT only as a short-term (e.g. few days) necessity to bridge the period until definitive wound closure can be established.
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Affiliation(s)
- Vera Sweere
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Susan Haidari
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Mertens
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Frank IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
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16
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Corona PS, Carbonell-Rosell C, Vicente M, Serracanta J, Tetsworth K, Glatt V. Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect. Arch Orthop Trauma Surg 2022; 142:3877-3887. [PMID: 34936017 PMCID: PMC9596551 DOI: 10.1007/s00402-021-04299-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes. MATERIALS AND METHODS A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. PRIMARY OUTCOMES limb salvage rate and infection eradication. SECONDARY OUTCOMES patient functional outcomes and satisfaction. RESULTS Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6-600) and 5.4 cm (1-23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were "very satisfied" with the treatment outcome. CONCLUSION A three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.
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Affiliation(s)
- Pablo S Corona
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carla Carbonell-Rosell
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Matías Vicente
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Serracanta
- Department of Plastic Surgery and Major Burn, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Orthopaedic Research Centre of Australia, Brisbane, Australia
| | - Vaida Glatt
- Orthopaedic Research Centre of Australia, Brisbane, Australia
- Department of Orthopaedic Surgery, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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Management of Common Postoperative Infections in the Surgical Intensive Care Unit. Infect Dis Clin North Am 2022; 36:839-859. [DOI: 10.1016/j.idc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Wang G, Alagboso FI, Walter N, Baertl S, Brochhausen C, Docheva D, Rupp M, Alt V. Bone regeneration after marginal bone resection in two-stage treatment of chronic long bone infection - a combined histopathological and clinical pilot study. Injury 2022; 53:3446-3457. [PMID: 35851476 DOI: 10.1016/j.injury.2022.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/06/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In chronic bone infection, marginal bone resection avoids large and difficult to reconstruct bone defects. However, there is still a lack of knowledge on bone regeneration during chronic bone infection and bone healing capability after marginal bone resection. Therefore, the purpose of this study was to investigate the clinical and histopathological outcomes after marginal bone resection in chronic long bone infection. We hypothesized that there is a regenerative bone healing potential after marginal bone resection that results in an acceptable clinical outcome and improved pathohistological bone healing parameters during treatment. MATERIALS AND METHODS Nine patients were treated for chronic bone infections in a two-stage manner with marginal bone resection of the infected area and the placement of an antibiotic-loaded polymethyl methacrylate (PMMA) spacer at stage one followed by bone reconstruction at stage two combined with systemic antibiotic therapy. Comparable bone samples were harvested at the border region between vital and necrotic bone area during stage one and the identical location during stage two. Control bone samples were harvested from five healthy patients without bone infection. Clinical outcome in terms of infection eradication and bone consolidation were assessed. The phenotypic changes of osteocyte and morphological changes of lacunar-canalicular network were investigated by histological and immunohistochemical staining between the two observation periods. Furthermore, expression levels of major bone formation and resorption markers were investigated by immunohistochemical and tartrate-resistant acid phosphatase (TRAP) staining. RESULTS The clinical results with a follow-up of 12.9 months showed that eight of nine patients (88.9%) achieved bone consolidation after a planned two-stage procedure of marginal resection of necrotic bone and consecutive reconstruction. In four of the nine patients (44.4%), additional marginal debridements after stage two had to be performed. After marginal resection at stage one, the improved bone formation ability at stage two was demonstrated by significantly lower percentage of empty lacunae, significantly more mature osteocytes and higher BMP-2 positive cell density, whereas decreased resorption was indicated by significantly lower osteoclast density and RANKL/OPG ratio. In patients requiring additional debridement compared to patients without additional debridements, a significantly higher percentage of empty lacunae was found at stage one. CONCLUSION Marginal bone resection combined with local and systemic antibiotic therapy is a feasible treatment option to avoid large bone defects as bone from the marginal resection area seems to have good regenerative potential. Despite a high revision rate of 44.4%, this technique avoids large bone resection and revisions can be done by further marginal debridements.
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Affiliation(s)
- Gongteng Wang
- Laboratory for Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany
| | - Francisca I Alagboso
- Laboratory for Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany
| | - Nike Walter
- Laboratory for Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany; Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany
| | - Susanne Baertl
- Laboratory for Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany; Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany
| | | | - Denitsa Docheva
- Laboratory for Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany; Department of Musculoskeletal Tissue Regeneration, Orthopaedic Hospital König-Ludwig-Haus, University of Wuerzburg, Germany
| | - Markus Rupp
- Laboratory for Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany; Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany.
| | - Volker Alt
- Laboratory for Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany; Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg 93053, Germany.
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Comment on Niemann et al. Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects. Diagnostics 2022, 12, 1207. Diagnostics (Basel) 2022; 12:diagnostics12102343. [PMID: 36292032 PMCID: PMC9600176 DOI: 10.3390/diagnostics12102343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/16/2022] [Indexed: 11/17/2022] Open
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Sambri A, Pignatti M, Tedeschi S, Lozano Miralles ME, Giannini C, Fiore M, Filippini M, Cipriani R, Viale P, De Paolis M. Combined Orthoplastic Approach in Fracture-Related Infections of the Distal Tibia. Microorganisms 2022; 10:microorganisms10081640. [PMID: 36014058 PMCID: PMC9414956 DOI: 10.3390/microorganisms10081640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/30/2022] Open
Abstract
This series reports on the treatment of distal tibia (DT) fracture-related infections (FRI) with a combined orthoplastic approach. Thirteen patients were included. In eight patients with extensive bone involvement and in those with a non-healed fracture, the DT was resected (“staged approach”). In five cases, the DT was preserved (“single-stage approach”). A wide debridement was performed, and the cavity was filled with antibiotic-loaded PerOssal beads. All patients had a soft-tissue defect covered by a free vascularized flap (anterolateral thigh perforator flap in eight cases, latissimus dorsi flap in five). At the final follow-up (mean 25 months, range, 13–37), no infection recurrence was observed. In one patient, the persistence of infection was observed, and the patient underwent a repeated debridement. In two cases, a voluminous hematoma was observed. However, none of these complications impacted the final outcome. The successful treatment of FRI depends on proper debridement and obliteration of dead spaces with a flap. Therefore, when dealing with DT FRI, debridement of infected bone and soft tissues must be as radical as required, with no fear of the need for massive reconstructions.
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Affiliation(s)
- Andrea Sambri
- Orthopaedics Unit, IRCCS AOU di Bologna, 40138 Bologna, Italy
- Correspondence:
| | - Marco Pignatti
- Plastic Surgery Unit, IRCCS AOU di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Sara Tedeschi
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Infectious Disease Unit, IRCCS AOU di Bologna, 40138 Bologna, Italy
| | | | | | - Michele Fiore
- Orthopaedics Unit, IRCCS AOU di Bologna, 40138 Bologna, Italy
| | | | | | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Infectious Disease Unit, IRCCS AOU di Bologna, 40138 Bologna, Italy
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McNally M, Corrigan R, Sliepen J, Dudareva M, Rentenaar R, IJpma F, Atkins BL, Wouthuyzen-Bakker M, Govaert G. What Factors Affect Outcome in the Treatment of Fracture-Related Infection? Antibiotics (Basel) 2022; 11:946. [PMID: 35884200 PMCID: PMC9312092 DOI: 10.3390/antibiotics11070946] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 12/24/2022] Open
Abstract
This international, multi-center study investigated the effect of individual components of surgery on the clinical outcomes of patients treated for fracture-related infection (FRI). All patients with surgically treated FRIs, confirmed by the FRI consensus definition, were included. Data were collected on demographics, time from injury to FRI surgery, soft tissue reconstruction, stabilization and systemic and local anti-microbial therapy. Patients were followed up for a minimum of one year. In total, 433 patients were treated with a mean age of 49.7 years (17−84). The mean follow-up time was 26 months (range 12−72). The eradication of infection was successful in 86.4% of all cases and 86.0% of unhealed infected fractures were healed at the final review. In total, 3.3% required amputation. The outcome was not dependent on age, BMI, the presence of metalwork or time from injury (recurrence rate 16.5% in FRI treated at 1−10 weeks after injury; 13.1% at 11−52 weeks; 12.1% at >52 weeks: p = 0.52). The debridement and retention of a stable implant (DAIR) had a failure rate of 21.4%; implant exchange to a new internal fixation had a failure rate of 12.5%; and conversion to external fixation had a failure rate of 10.3% (adjusted hazard ratio (aHR) DAIR vs. Ext Fix 2.377; 95% C.I. 0.96−5.731). Tibial FRI treated with a free flap was successful in 92.1% of cases and in 80.4% of cases without a free flap (HR 0.38; 95% C.I. 0.14−1.0), while the use of NPWT was associated with higher recurrence rates (HR 3.473; 95% C.I. 1.852−6.512). The implantation of local antibiotics reduced the recurrence from 18.7% to 10.0% (HR 0.48; 95% C.I. 0.29−0.81). The successful treatment of FRI was multi-factorial. These data suggested that treatment decisions should not be based on time from injury alone, as other factors also affected the outcome. Further work to determine the best indications for DAIR, free flap reconstruction and local antibiotics is warranted.
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Affiliation(s)
- Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
| | - Ruth Corrigan
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
- Nuffield Department of Clinical Laboratory Sciences, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands; (J.S.); (F.I.)
| | - Maria Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
| | - Rob Rentenaar
- Department of Medical Microbiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Frank IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands; (J.S.); (F.I.)
| | - Bridget L. Atkins
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 9DU, UK; (R.C.); (M.D.); (B.L.A.)
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, 9712 CP Groningen, The Netherlands;
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands;
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22
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Tissingh EK, Marais L, Loro A, Bose D, Ferguson J, Morgensten M, McNally M. Management of fracture-related infection in low resource settings: how applicable are the current consensus guidelines? EFORT Open Rev 2022; 7:422-432. [PMID: 35638596 PMCID: PMC9257735 DOI: 10.1530/eor-22-0031] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The global burden of fracture-related infection (FRI) is likely to be found in countries with limited healthcare resources and strategies are needed to ensure the best available practice is context appropriate. This study has two main aims: (i) to assess the applicability of recently published expert guidance from the FRI consensus groups on the diagnosis and management of FRI to low- and middle-income countries (LMICs); (ii) to summarise the available evidence on FRI, with consideration for strategies applicable to low resource settings. Data related to the International Consensus Meeting Orthopaedic Trauma Work Group and the International Fracture Related Infection Consensus Group FRI guidelines were collected including panel membership, country of origin, language of publication, open access status and impact factor of the journal of publication. The recommendations and guidelines were then summarised with specific consideration for relevance and applicability to LMICs. Barriers to implementation were explored within a group of LMIC residents and experienced workers. The authorship, evidence base and reach of the FRI consensus guidelines lack representation from low resource settings. The majority of authors (78.5–100%) are based in high-income countries and there are no low-income country collaborators listed in any of the papers. All papers are in English. The FRI consensus guidelines give a clear set of principles for the optimum management of FRI. Many of these – including the approach to diagnosis, multidisciplinary team working and some elements of surgical management – are achievable in low resource settings. Current evidence suggests that it is important that a core set of principles is prioritised but robust evidence for this is lacking. There are major organisational and infrastructure obstacles in LMICs that will make any standardisation of FRI diagnosis or management challenging. The detail of how FRI consensus principles should be applied in low resource settings requires further work. The important work presented in the current FRI consensus guidelines is relevant to low resource settings. However, leadership, collaboration, creativity and innovation will be needed to implement these strategies for communities who need it the most.
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Affiliation(s)
- Elizabeth K Tissingh
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.,King's Global Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Leonard Marais
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Antonio Loro
- Comprehensive Rehabilitation Services for People with Disability in Uganda (CoRSU) Hospital, Kisubi, Uganda
| | - Deepa Bose
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.,Oxford Trauma Unit, Oxford University Hospitals, Oxford, UK
| | - Mario Morgensten
- Centre for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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23
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Nasser AAH, Fenton P, Bose D. Single stage versus two-stage orthoplastic management of bone infection. Injury 2022; 53:984-991. [PMID: 35063261 DOI: 10.1016/j.injury.2022.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention. METHODS Using an existing 2009-2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre. RESULTS A total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts. CONCLUSIONS The single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.
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Affiliation(s)
- Ahmed A H Nasser
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK.
| | - Paul Fenton
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
| | - Deepa Bose
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
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24
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Tang B, Zhu W. Progress in diagnosis and treatment of post-traumatic osteomyelitis. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:1290-1297. [PMID: 34911865 PMCID: PMC10929846 DOI: 10.11817/j.issn.1672-7347.2021.200621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Indexed: 11/03/2022]
Abstract
Post-traumatic osteomyelitis is one of the most common disorders of bone infection, which is secondary to open fracture caused by machinery injury, traffic accident, and it is also the main manifestation in the postoperative infection of open fracture. After trauma, bacteria invade bone tissue and reproduce rapidly in large quantities, which easily leads to osteomyelitis. Patients are often complaint of pain at the affected limb, loss of function, or even amputation due to deteriorated infection, resulting in loss of labor capability and poor quality of life. Because the diagnosis and treatment are not timely and standard, the treatment for post-traumatic osteomyelitis is often delayed, resulting in the difficulty of clinical cure. It also makes patients and their families bear a serious financial burden. However, the diagnosis and treatment for this disease is difficult for orthopedic physicians. In recent years, imaging methods (such as CT and MRI) combined with immune techniques have significantly improved the diagnostic accuracy and early diagnosis ability. The application of new diagnostic technologies (such as gene chip and second-generation sequencing) also makes the diagnosis more convenient and sensitive. The novel reconstruction and repair surgery (such as Ilizarov technology and Orthofix LRS technology) provides new treatment direction for orthopedic surgeons and patients.
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Affiliation(s)
- Buqi Tang
- Xiangya School of Medicine, Central South University, Changsha 410013.
| | - Weihong Zhu
- Department of Orthopedics, Second Xiangya Hospital, Central South University, Changsha 410011, China.
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25
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Current opinions on the mechanism, classification, imaging diagnosis and treatment of post-traumatic osteomyelitis. Chin J Traumatol 2021; 24:320-327. [PMID: 34429227 PMCID: PMC8606609 DOI: 10.1016/j.cjtee.2021.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 02/04/2023] Open
Abstract
Post-traumatic osteomyelitis (PTO) is a worldwide problem in the field of orthopaedic trauma. So far, there is no ideal treatment or consensus-based gold standard for its management. This paper reviews the representative literature focusing on PTO, mainly from the following four aspects: (1) the pathophysiological mechanism of PTO and the interaction mechanism between bacteria and the body, including fracture stress, different components of internal fixation devices, immune response, occurrence and development mechanisms of inflammation in PTO, as well as the occurrence and development mechanisms of PTO in skeletal system; (2) clinical classification, mainly the etiological classification, histological classification, anatomical classification and the newly proposed new classifications (a brief analysis of their scope and limitations); (3) imaging diagnosis, including non-invasive examination and invasive examination (this paper discusses their advantages and disadvantages respectively, and briefly compares the sensitivity and effectiveness of the current examinations); and (4) strategies, including antibiotic administration, surgical choices and other treatment programs. Based on the above-mentioned four aspects, we try to put forward some noteworthy sections, in order to make the existing opinions more specific.
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26
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Müller SLC, Morgenstern M, Kuehl R, Muri T, Kalbermatten DF, Clauss M, Schaefer DJ, Sendi P, Osinga R. Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis. Injury 2021; 52:3489-3497. [PMID: 34304885 DOI: 10.1016/j.injury.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.
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Affiliation(s)
- Seraina L C Müller
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland.
| | - Richard Kuehl
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Thaddaeus Muri
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Dirk J Schaefer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Parham Sendi
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland; Institute for Infectious Diseases, University of Bern, Switzerland
| | - Rik Osinga
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
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27
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Haidari S, IJpma FFA, Metsemakers WJ, Maarse W, Vogely HC, Ramsden AJ, McNally MA, Govaert GAM. The Role of Negative-Pressure Wound Therapy in Patients with Fracture-Related Infection: A Systematic Review and Critical Appraisal. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7742227. [PMID: 34722772 PMCID: PMC8548908 DOI: 10.1155/2021/7742227] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Fracture-related infection (FRI) is a severe musculoskeletal complication in orthopedic trauma surgery, causing challenges in bony and soft tissue management. Currently, negative-pressure wound therapy (NPWT) is often used as temporary coverage for traumatic and surgical wounds, also in cases of FRI. However, controversy exists about the impact of NPWT on the outcome in FRI, specifically on infection recurrence. Therefore, this systematic review qualitatively assesses the literature on the role of NPWT in the management of FRI. METHODS A literature search of the PubMed, Embase, and Web of Science database was performed. Studies that reported on infection recurrence related to FRI management combined with NPWT were eligible for inclusion. Quality assessment was done using the PRISMA statement and the Newcastle-Ottawa Quality Assessment Scale. RESULTS After screening and quality assessment of 775 unique identified records, eight articles could be included for qualitative synthesis. All eight studies reported on infection recurrence, which ranged from 2.8% to 34.9%. Six studies described wound healing time, varying from two to seven weeks. Four studies took repeated microbial swabs during subsequent vacuum dressing changes. One study reported newly detected pathogens in 23% of the included patients, and three studies did not find new pathogens. CONCLUSION This review provides an assessment of current literature on the role of NPWT in the management of soft tissue defects in patients with FRI. Due to the lack of uniformity in included studies, conclusions should be drawn with caution. Currently, there is no clear scientific evidence to support the use of NPWT as definitive treatment in FRI. At this stage, we can only recommend early soft tissue coverage (within days) with a local or free flap. NPWT may be safe for a few days as temporarily soft tissue coverage until definitive soft tissue management could be performed. However, comparative studies between NPWT and early wound closure in FRI patients are needed.
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Affiliation(s)
- Susan Haidari
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | | | - Wies Maarse
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - H. Charles Vogely
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Alex J. Ramsden
- Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Bone Infection Unit, Nuffield Orthopedic Centre, Oxford, UK
| | | | - Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Distally based hemisoleus flap for soft tissue defect closure following chronic osteomyelitis of the distal tibia: A case report. Int J Surg Case Rep 2021; 87:106437. [PMID: 34562719 PMCID: PMC8477992 DOI: 10.1016/j.ijscr.2021.106437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/19/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Chronic osteomyelitis often needs extensive debridement that leaves a gap and needs soft tissue reconstruction procedure. The use of pedicled versus free flap to reconstruct soft tissue following surgical debridement has long been debated. Pedicle flap is more favored by many surgeons for the distal third tibia, mainly due to its lower failure rate. CASE PRESENTATION We report a 33-year-old man with eight years of chronic osteomyelitis treated with surgical debridement at the distal third tibia, leaving a 5 cm × 6 cm soft tissue defect with exposed bone. Against the common preference, we performed a distally based hemisoleus flap (pedicled flap) covered with a split thickness skin graft. No signs of flap/graft rejection were observed during follow-up, and the patient was able to return to work four months following the surgery. No limitation in patient's daily activity upon two years follow up. CLINICAL DISCUSSION Preservation of critical perforators is essential during the elevation of the flap. The knowledge and application of the vascularity and angiosome principles are crucial in designing this type of flap, as some anatomical variations do exist. Meticulous tissue handling is required to support the basic knowledge of the lower limb vascular system. CONCLUSION Distally based hemisoleus flap is a reasonable option for soft tissue defect following chronic osteomyelitis of the distal tibia.
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29
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Galitzine S, Wilson K, Edington M, Burumdayal A, McNally M. Patients' reported experiences and outcomes following surgical excision of lower limb osteomyelitis and microvascular free tissue reconstruction under 'awake' epidural anaesthesia and sedation. Surgeon 2021; 19:193-199. [PMID: 32616367 PMCID: PMC7323658 DOI: 10.1016/j.surge.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/29/2020] [Accepted: 05/07/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Orthoplastic operations for lower limb osteomyelitis (LLOM) involving microvascular free tissue reconstructions ("free-flaps") are usually performed under general anaesthesia (GA), with or without epidural anaesthesia (EA) due to concerns about the discomfort associated with prolonged surgery. However, our clinical experience supports "awake" epidural anaesthesia with sedation (EA + Sed) rather than EA + GA as a technique of choice for this type of surgery. METHODS We used a standardised postoperative questionnaire to formally assess the experiences and outcomes for 50 patients who underwent free-flaps for LLOM under EA + Sed. FINDINGS The mean duration of surgery was 522 min (8.7 h), range 240-875 min. There were no ITU admissions or flap failures. Postoperatively, fifty patients completed a standardised questionnaire about their experiences before the operation, in the anaesthetic room and theatre. 80% were aware of the procedure at least "some of the time". 72.5% patients and 75% respectively, did not have any concerns in the anaesthetic room and theatre. Concerns expressed by the remaining patients were manageable. 97.5% of those patients who recalled their operation reported their overall experience as "comfortable" or "very comfortable". 92% of respondents had undergone previous lower limb surgery under GA ± EA. In this subgroup, 91.3% reported the recovery after EA + Sed as "quicker" than GA, and 89.4% reported their experience with EA + Sed as "better". All fifty patients (100%) were "satisfied" or "very satisfied" with their experience and all but one (98%) would recommend this technique to others. CONCLUSIONS Our study showed that despite prolonged duration, the patients' reported experiences and outcomes were excellent when EA + Sed was used for orthoplastic operations involving free-flaps for LLOM. We recommend EA + Sed as the anaesthetic technique of choice for such patients.
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Affiliation(s)
- Svetlana Galitzine
- Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
| | - Katy Wilson
- Anaesthetic ST6, Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
| | | | - Amisha Burumdayal
- Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, UK.
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.
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30
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Zhang S, Yang K, Wang Q, Hou J, Zang H, Luo S, Zhang T, Zhang X. Treatment of Fractures of Metatarsal Shaft Using a Cemented K-wire Frame. J Foot Ankle Surg 2021; 60:42-46. [PMID: 33218864 DOI: 10.1053/j.jfas.2020.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 12/17/2019] [Accepted: 05/11/2020] [Indexed: 02/03/2023]
Abstract
The purpose of this retrospective study was to report on percutaneous reduction and fixation for the treatment of fractures of metatarsal shaft. Between March 2015 and October 2017, 29 patients (37 fractures of metatarsal shaft) were treated using a cemented Kirschner wire (K-wire) frame. The accuracy of reduction of the fragments was assessed as anatomic (0 to 8 points), good (9 to 11 points), fair (12 to 15 points), or poor (>15 points). The Maryland foot score was used to assess pain and functional outcomes. All fractures were reduced using percutaneous techniques. Anatomic reduction was achieved in 31 metatarsal fractures (84%), and good reduction was achieved in 6 (16%). The average bone healing time was 7 weeks (range, 4 to 16). Pin tract infection was noted in 2 metatarsal bones, which healed with pin site care. The mean cost of the cemented K-wire frame was US$335 (range, $283 to $385) per patient. Based on the Maryland foot score, there were 26 excellent results (90%) and 3 good results (10%). The cemented K-wire frame is a useful external fixator and can be an alternative for treating fractures of metatarsal shaft, especially when open surgeries are a major concern owing to severely damaged soft-tissue envelope. The system is cheap and easy to apply and provides rigid fixation, resulting in good function of the foot.
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Affiliation(s)
- Shenghua Zhang
- Professor, Department of Orthopaedics, Qinhuangdao Orthopaedics Hospital, Qinhuangdao, Hebei, China
| | - Kun Yang
- Orthopedic Surgeon, Department of Orthopaedics, Qinhuangdao Orthopaedics Hospital, Qinhuangdao, Hebei, China
| | - Qi Wang
- Professor, Department of Orthopaedics, Qinhuangdao Orthopaedics Hospital, Qinhuangdao, Hebei, China
| | - Jiguang Hou
- Orthopedic Surgeon, Department of Orthopaedics, Qinhuangdao Orthopaedics Hospital, Qinhuangdao, Hebei, China
| | - Hongwei Zang
- Orthopedic Surgeon, Department of Orthopaedics, Qinhuangdao Orthopaedics Hospital, Qinhuangdao, Hebei, China
| | - Shi Luo
- Orthopedic Surgeon, Department of Orthopaedics, Qinhuangdao Orthopaedics Hospital, Qinhuangdao, Hebei, China
| | - Tao Zhang
- Orthopedic Surgeon, Department of Orthopaedics, Qinhuangdao Orthopaedics Hospital, Qinhuangdao, Hebei, China
| | - Xu Zhang
- Professor, Department of Hand Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
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Mifsud M, Ferguson JY, Stubbs DA, Ramsden AJ, McNally MA. Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection. J Bone Jt Infect 2020; 6:63-72. [PMID: 33552880 PMCID: PMC7852407 DOI: 10.5194/jbji-6-63-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic bone infections often present with complex bone and soft tissue
loss. Management is difficult and commonly delivered in multiple stages over
many months. This study investigated the feasibility and clinical outcomes
of reconstruction in one stage. Fifty-seven consecutive patients with chronic osteomyelitis (n=27) or
infected non-union (n=30) were treated with simultaneous debridement,
Ilizarov method and free muscle flap transfer. 41 patients (71.9 %) had
systemic co-morbidities (Cierny-Mader group Bs hosts). Infection was
confirmed with strict criteria. 48 patients (84.2 %) had segmental
defects. The primary outcome was eradication of infection at final follow-up.
Secondary outcomes included bone union, flap survival and complications or
re-operation related to the reconstruction. Infection was eradicated in 55/57 cases (96.5 %) at a mean follow-up of 36 months (range 12–146). No flap failures occurred during distraction but 6
required early anastomotic revision and 3 were not salvageable (flap failure
rate 5.3 %). Bony union was achieved in 52/57 (91.2 %) with the initial surgery alone.
After treatment of the five un-united docking sites, all cases achieved bony
union at final follow-up. Simultaneous reconstruction with Ilizarov method and free tissue transfer is
safe but requires careful planning and logistic considerations. The outcomes
from this study are equivalent or better than those reported after staged
surgery.
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Affiliation(s)
- Max Mifsud
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - Jamie Y Ferguson
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - David A Stubbs
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - Alex J Ramsden
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - Martin A McNally
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
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Osinga R, Eggimann MM, Lo SJ, Kühl R, Lunger A, Ochsner PE, Sendi P, Clauss M, Schaefer DJ. Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency. J Bone Jt Infect 2020; 5:160-171. [PMID: 32566456 PMCID: PMC7295645 DOI: 10.7150/jbji.47018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction: Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years. Methods and Results: One-hundred sixty patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 47 patients. Of these, six presented with extensor apparatus deficiency. One patient underwent primary arthrodesis and five patients underwent reconstruction of the extensor apparatus. The principle to reconstruct missing tissue 'like with like' was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and two patients who did not qualify for free flap surgery received a pedicled medial sural artery perforator gastrocnemius flap. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo arthrodesis because of recurrent infection and one patient was lost to follow-up. Conclusion: These results show that PJI of the knee and extensor apparatus deficiency is a dreaded combination with a poor long-term outcome. Standardization of surgical techniques for a defined PJI problem and consensus on study variables may facilitate interinstitutional comparisons of outcome data, and hence, improvement of treatment concepts.
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Affiliation(s)
- Rik Osinga
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, United Kingdom
| | | | - Steven John Lo
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, United Kingdom.,Translational Research Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Richard Kühl
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Alexander Lunger
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Peter Emil Ochsner
- Clinic for Orthopedics and Trauma Surgery and Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland, Liestal, Switzerland
| | - Parham Sendi
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.,Institute for Infectious Diseases, University of Bern, Bern, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Clauss
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Clinic for Orthopedics and Trauma Surgery and Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland, Liestal, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Dirk Johannes Schaefer
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
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Sigmund IK, Ferguson J, Govaert GA, Stubbs D, McNally MA. Comparison of Ilizarov Bifocal, Acute Shortening and Relengthening with Bone Transport in the Treatment of Infected, Segmental Defects of the Tibia. J Clin Med 2020; 9:E279. [PMID: 32012855 PMCID: PMC7074086 DOI: 10.3390/jcm9020279] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/19/2022] Open
Abstract
This prospective study compared bifocal acute shortening and relengthening (ASR) with bone transport (BT) in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at the surgical resection of the infection. Patients with an infected tibial segmental defect (>2 cm) were eligible for inclusion. Patients were allocated to ASR or BT, using a standardized protocol, depending on defect size, the condition of soft tissues and the state of the fibula (intact or divided). We recorded the Weber-Cech classification, previous operations, external fixation time, external fixation index (EFI), follow-up duration, time to union, ASAMI bone and functional scores and complications. A total of 47 patients (ASR: 20 patients, BT: 27 patients) with a median follow-up of 37.9 months (range 16-128) were included. In the ASR group, the mean bone defect size measured 4.0 cm, and the mean frame time was 8.8 months. In the BT group, the mean bone defect size measured 5.9cm, and the mean frame time was 10.3 months. There was no statistically significant difference in the EFI between ASR and BT (2.0 and 1.8 months/cm, respectively) (p = 0.223). A total of 3/20 patients of the ASR and 15/27 of the BT group needed further unplanned surgery during Ilizarov treatment (p = 0.006). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.0% (p < 0.0001). The infection eradication rate was 100% in both groups at final follow-up. Final ASAMI functional rating scores and bone scores were similar in both groups. Segmental resection with the Ilizarov method is effective and safe for reconstruction of infected tibial defects, allowing the eradication of infection and high union rates. However, BT demonstrated a higher rate of unplanned surgeries, especially docking site revisions. Acute shortening and relengthening does not reduce the fixator index. Both techniques deliver good functional outcome after completion of treatment.
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Affiliation(s)
- Irene K. Sigmund
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Foundation NHS Trust, Windmill Rd, Headington, Oxford OX3 7HE, UK; (I.K.S.); (J.F.); (D.S.)
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, Vienna 1090, Austria
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Foundation NHS Trust, Windmill Rd, Headington, Oxford OX3 7HE, UK; (I.K.S.); (J.F.); (D.S.)
| | - Geertje A.M. Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Centre Utrecht (UMCU), 3512 Utrecht, The Netherlands;
| | - David Stubbs
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Foundation NHS Trust, Windmill Rd, Headington, Oxford OX3 7HE, UK; (I.K.S.); (J.F.); (D.S.)
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Foundation NHS Trust, Windmill Rd, Headington, Oxford OX3 7HE, UK; (I.K.S.); (J.F.); (D.S.)
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Gao E, Zhang X, Han M, Zhang Y, Zhao C, Wang Z, Guo Z. Refractory Infection After Internal Fixation for Rib Fractures. Ann Thorac Surg 2019; 110:e43-e45. [PMID: 31881196 DOI: 10.1016/j.athoracsur.2019.10.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/13/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
The infection of internal fixation devices of rib fractures is rare, but it is usually severe when it occurs. Existing literature indicates that removal of infected hardware is essential for the clearance of refractory infection. We report a rare case of a patient who accepted operation for rib fractures; however, his hardware infection was not controlled after the removal of internal fixation devices, until the necrotic ribs were removed by the third operation.
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Affiliation(s)
- Erji Gao
- Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xufeng Zhang
- Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Min Han
- Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yongkai Zhang
- Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chuncheng Zhao
- Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zheng Wang
- Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhiqiang Guo
- Department of Thoracic Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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