Hardware considerations in infection and nonunion management: When and how to revise the fixation

Emerging Indications for Hyperbaric Oxygen Treatment: Registry Cohort Study

BACKGROUND

Hyperbaric oxygen (HBO2) treatment is used across a range of medical specialties for a variety of applications, particularly where hypoxia and inflammation are important contributors. Because of its hypoxia-relieving and anti-inflammatory effects HBO2 may be useful for new indications not currently approved by the Undersea and Hyperbaric Medical Society. Identifying these new applications for HBO2 is difficult because individual centers may only treat a few cases and not track the outcomes consistently. The web-based International Multicenter Registry for Hyperbaric Oxygen Therapy captures prospective outcome data for patients treated with HBO2 therapy. These data can then be used to identify new potential applications for HBO2, which has relevance for a range of medical specialties.

OBJECTIVE

Although hyperbaric medicine has established indications, new ones continue to emerge. One objective of this registry study was to identify cases where HBO2 has been used for conditions falling outside of current Undersea and Hyperbaric Medical Society-approved indications and present outcome data for them.

METHODS

This descriptive study used data from a web-based, multicenter, international registry of patients treated with HBO2. Participating centers agree to collect data on all patients treated using standard outcome measures, and individual centers send deidentified data to the central registry. HBO2 treatment programs in the United States, the United Kingdom, and Australia participate. Demographic, outcome, complication, and treatment data, including pre- and posttreatment quality of life questionnaires (EQ-5D-5L) were collected for individuals referred for HBO2 treatment.

RESULTS

Out of 9726 patient entries, 378 (3.89%) individuals were treated for 45 emerging indications. Post-COVID-19 condition (PCC; also known as postacute sequelae of COVID-19; 149/378, 39.4%), ulcerative colitis (47/378, 12.4%), and Crohn disease (40/378, 10.6%) accounted for 62.4% (n=236) of the total cases. Calciphylaxis (20/378, 5.3%), frostbite (18/378, 4.8%), and peripheral vascular disease-related wounds (12/378, 3.2%) accounted for a further 13.2% (n=50). Patients with PCC reported significant improvement on the Neurobehavioral Symptom Inventory (NSI score: pretreatment=30.6; posttreatment=14.4; P<.001). Patients with Crohn disease reported significantly improved quality of life (EQ-5D score: pretreatment=53.8; posttreatment=68.8), and 5 (13%) reported closing a fistula. Patients with ulcerative colitis and complete pre- and post-HBO2 data reported improved quality of life and lower scores on a bowel questionnaire examining frequency, blood, pain, and urgency. A subset of patients with calciphylaxis and arterial ulcers also reported improvement.

CONCLUSIONS

HBO2 is being used for a wide range of possible applications across various medical specialties for its hypoxia-relieving and anti-inflammatory effects. Results show statistically significant improvements in patient-reported outcomes for inflammatory bowel disease and PCC. HBO2 is also being used for frostbite, pyoderma gangrenosum, pterygium, hypospadias repair, and facial filler procedures. Other indications show evidence for improvement, and the case series for all indications is growing in the registry.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/18857.

The induced membrane technique for the management of infected segmental bone defects

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

Methods

Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis.

Results

Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time.

Conclusion

The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction.

Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing

PURPOSE

The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity.

METHODS

An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts.

RESULTS

Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001).

CONCLUSION

Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture.

LEVEL OF EVIDENCE

III.

Fracture-Related Infection-Epidemiology, Etiology, Diagnosis, Prevention, and Treatment

BACKGROUND

Fracture-related infection (FRI) is a challenge to physicians and other workers in health care. In 2018, there were 7253 listed cases of FRI in Germany, corresponding to an incidence of 10.7 cases per 100 000 persons per year.

METHODS

This review is based on pertinent publications retrieved from a search in PubMed with the search terms "fracture," "infection," "guideline," and "consensus." Aside from the primary literature, international guidelines and consensus recommendations were evaluated as well.

RESULTS

FRI arise mainly from bacterial contamination of the fracture site. Staphylococcus aureus is the most commonly detected pathogen. The treatment is based on surgery and antibiotics and should be agreed upon by an interdisciplinary team; it is often difficult because of biofilm formation. Treatment options include implant-preserving procedures and single-stage, two-stage, or multi-stage implant replacement. Treatment failure occurs in 10.3% to 21.4% of cases. The available evidence on the efficacy of various treatment approaches is derived mainly from retrospective cohort studies (level III evidence). Therefore, periprosthetic joint infections and FRI are often discussed together.

CONCLUSION

FRI presents an increasing challenge. Preventive measures should be optimized, and the treatment should always be decided upon by an interdisciplinary team. Only low-level evidence is available to date to guide diagnostic and treatment decisions. High-quality studies are therefore needed to help us meet this challenge more effectively.

Antibiotic-Coated Intramedullary Nailing Managing Long Bone Infected Non-Unions: A Meta-Analysis of Comparative Studies

Long bone infected non-unions are such an orthopedic challenge that antibiotic-coated intramedullary nailing (ACIN) has become a viable therapeutic option for their management. This study aims to provide a comprehensive assessment of the available data about the use of antibiotic-coated nailing in the treatment of long bone infected non-unions. Following the PRISMA guideline in this meta-analysis, a systematic literature search was conducted across major databases for studies evaluating ACIN in long bone infected non-unions. The primary outcome measures included union rates, infection control, complications and functional status. Five eligible studies encompassing 183 patients in total met the inclusion criteria. The meta-analysis revealed no difference in the union rate in the antibiotic-coated intramedullary nailing group compared to that of the control group (OR = 1.73 [0.75-4.02]). Antibiotic-coated intramedullary nailing demonstrated no association with higher infection eradication (OR = 2.10 [0.97-4.54]). Also, functional outcome measure was mostly not significantly different between ACIN and control interventions. According to this meta-analysis, compared to the management of controls, ACIN is neither linked to increased union rates nor decreased infection rates. The paucity of research on this topic emphasizes the continuous need for additional well-designed randomized controlled trials for the application of antibiotics-coated intramedullary nailing in long bone non-unions.

Can "Aseptic" Looking TIBIA Non-union be Result of an Unrecognized Subclinical Infection?

Introduction

The usual cause of a distal tibial fracture is a high-energy trauma. Although multiple options are available for their treatment such as intramedullary nailing, open plating, and external fixator, each of these options might result in a non-union. Knowing the type of non-union not only allows us to guess the cause but also directs us toward the best possible treatment. Despite this, we might still get surprises on the operating table due to pre-operative misdiagnosis.

Case Report

Reporting a case of a 42-year-old male with a 15-month-old left distal tibia non-union. The index injury was a grade 1 distal third tibia fibula fracture which was fixed with a plate and screws 15 months back. All the clinical and biochemical signs hinted toward the diagnosis of an aseptic non-union and the treatment was planned accordingly. However, intraoperative findings were much different due to which the surgeons had to improvise and change the intervention to an antibiotic-coated nail.

Conclusion

Although each variety of non-union has its set of signs and symptoms, they can be misleading. Different etiologies can coexist making it difficult to give a perfect pre-operative diagnosis and management. Non-unions, especially in the tibia, thus need meticulous understanding of the underlying disease process and extensive treatment strategies.

Biomechanical Performance of Total Wrist Arthrodesis Plates With and Without Arthrodesis of the Carpometacarpal Joint

BACKGROUND

It is unknown whether total wrist arthrodesis (TWA) should be performed with or without arthrodesis of the carpometacarpal joint (CMCJ). The aim of this study is to compare CMCJ-spanning TWA plates using 3D printed wrist arthrodesis model with and without arthrodesis of the CMCJ.

METHODS

Total wrist arthrodesis plates mounted to 3D printed models were tested under a 4-N bending load at 4 Hz for 50 000 cycles, increased by 15% every 10 000 cycles until failure.

RESULTS

Plates with arthrodesis CMCJ were stiffer and failed at a significantly greater load and number of cycles than plates mounted to models without CMCJ arthrodesis. The Synthes stainless steel locking TWA plate performed better than the Trimed plate applied to the model without CMCJ arthrodesis and the Acumed plate applied to the model with CMCJ arthrodesis. Based on these findings, we recommend arthrodesis of the CMCJ in TWA.

CONCLUSIONS

Incorporation of the CMCJ in TWA may protect against plate failure. If arthrodesis of the CMCJ is not performed, plate removal should be considered before breakage occurs.

LEVEL OF EVIDENCE

IV.

Early Resistance Rehabilitation Improves Functional Regeneration Following Segmental Bone Defect Injury

Mechanical loading is integral to bone development and repair. The application of mechanical loads through rehabilitation are regularly prescribed as a clinical aide following severe bone injuries. However, current rehabilitation regimens typically involve long periods of non-loading and rely on subjective patient feedback, leading to muscle atrophy and soft tissue fibrosis. While many pre-clinical studies have focused on unloading, ambulatory loading, or direct mechanical compression, rehabilitation intensity and its impact on the local strain environment and subsequent bone healing have largely not been investigated. This study combines implantable strain sensors and subject-specific finite element models in a pre-clinical rodent model with a defect size on the cusp of critically-sized. Animals were enrolled in either high or low intensity rehabilitation one week post injury to investigate how rehabilitation intensity affects the local mechanical environment and subsequent functional bone regeneration. The high intensity rehabilitation animals were given free access to running wheels with resistance, which increased local strains within the regenerative niche by an average of 44% compared to the low intensity (no-resistance) group. Finite element modeling demonstrated that resistance rehabilitation significantly increased compressive strain by a factor of 2.0 at week 1 and 4.45 after 4 weeks of rehabilitation. The resistance rehabilitation group had significantly increased regenerated bone volume and higher bone bridging rates than its sedentary counterpart (bone volume: 22.00 mm3 ± 4.26 resistance rehabilitation vs 8.00 mm3 ± 2.27 sedentary; bridging rates: 90% resistance rehabilitation vs 50% sedentary). In addition, animals that underwent resistance running had femurs with improved mechanical properties compared to those left in sedentary conditions, with failure torque and torsional stiffness values matching their contralateral, intact femurs (stiffness: 0.036 Nm/deg ± 0.006 resistance rehabilitation vs 0.008 Nm/deg ± 0.006 sedentary). Running on a wheel with no resistance rehabilitation also increased bridging rates (100% no resistance rehabilitation vs 50% sedentary). Analysis of bone volume and von Frey suggest no-resistance rehabilitation may improve bone regeneration and hindlimb functionality. These results demonstrate the potential for early resistance rehabilitation as a rehabilitation regimen to improve bone regeneration and functional recovery.

Fracture-related infections

Fracture-related infection is a serious complication which can occur following musculoskeletal injury and is associated with significant morbidity. These complications can be challenging to recognise, and experts have provided a clearer definition of fracture-related infection to help with the diagnosis and detection of these infections. This system includes clinical, radiological and laboratory-based diagnostic features which are either confirmatory or suggestive of fracture-related infection. Treatment requires a multifaceted approach with multidisciplinary involvement, and generally a combination of surgical techniques and prolonged antibiotics, the timing and choice of which should be optimised. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of fracture-related infections.

Etiologies of Orthopedic Implant Removal Among Patients Who Underwent Orthopedic Fixation Surgeries in King Abdulaziz Medical City

BACKGROUND

Hardware removal surgeries are considerably common. However, the justifications for these surgeries are debatable. The indications may vary from pain, surgical site infection, or failure of osteosynthesis. Additionally, the surgery can be performed without medical indication. Following these surgeries, many complications can occur. Therefore, surgeons and patients should be aware of the appropriate indications and have realistic expectations of the risks and benefits of implant removal.

METHODS

This was a retrospective chart review study. We included all patients aged 17-86 years who underwent hardware removal surgery in the orthopedic surgery department of King Abdulaziz Medical City, Riyadh, Saudi Arabia, from 2010 to 2019. All relevant data, such as demographic characteristics, location and type of hardware, indication for hardware removal, duration between insertion and removal, and complications after removal were recorded and analyzed.

RESULTS

A total of 244 medical records were reviewed with a mean patient age of 34 years. Out of the total, 190 patients (77.9%) were male. The femur was the most common location of hardware removal, in 50 cases (20.58%). Plates and screws were the most common type of implants (40.2%). Most patients underwent hardware implantation because of fractures (89.3%). In total, 119 patients (48.8%) had the hardware removed electively. Only 29 patients (12%) reported postoperative complications; 190 patients (77.9%) were advised by their surgeon against hardware removal.

CONCLUSION

Hardware removal procedures are commonly performed worldwide for various reasons, including infection, pain, and loosening. In this study, we have outlined the reasons for implant removal, the locations, complications, and the rationale behind this surgery. We have provided a new decision-making assessment, aimed at the general population and surgeons alike, that will help patients better comprehend the complications and risks associated with this elective surgery.

Management of ACL Reconstruction Complicated by MRSA Osteomyelitis Requiring a Gastrocnemius Perforator Flap: A Case Report

CASE

A 21-year-old woman presented with sepsis from methicillin-resistant Staphylococcus aureus, patellar osteomyelitis, and 6 × 4 × 2-cm proximal anteromedial soft-tissue defect 1 week after bone-tendon-bone autograft anterior cruciate ligament reconstruction (ACL-R). She underwent multiple irrigation and debridement (I&Ds), hardware removal, bone grafting with antibiotic-loaded tricalcium phosphate beads, and medial gastrocnemius perforator flap with plastic surgery. At 18 months after her initial ACL-R, single-stage revision ACL-R with quadriceps autograft was performed.

CONCLUSION

When acute ACL-R infection does not respond to initial I&D and Intravenous (IV) antibiotics, retained hardware and graft tissue must be removed expeditiously to prevent sepsis, osteomyelitis, and soft-tissue defects.

Hardware Salvage in the Lower Extremity after Flap Coverage: 10-Year Single Center Outcomes Analysis

An unanswered question with open tibial fractures is whether the type of flap used affects hardware retention. Flap survival may not equate hardware retention or limb salvage. In this study, we performed a 10-year single institution review and analysis of all patients who had placement of hardware for open tibial fractures followed by flap coverage.

Methods

Inclusion criteria consisted of patients who underwent pedicled or free flap coverage of Gustilo IIIB or IIIC tibial fractures requiring open reduction and internal fixation. Outcomes and complications were statistically analyzed based on flap type. Flap type was stratified into free versus pedicled flaps and muscle versus fasciocutaneous flaps. Primary outcome measures included hardware failure and infection requiring hardware removal. Secondary outcome measures included limb salvage, flap success, and fracture union.

Results

Overall primary outcome measures were better for pedicled flaps (n = 31), with lower rates of hardware failure and infection (25.8%; 9.7%) compared with free flaps (n = 27) (51.9%; 37.0%). Limb salvage and flap success was not different comparing pedicled and free flaps. There was no significant difference in outcomes between muscle and fasciocutaneous flaps. Multivariable analysis showed that patients who had free versus pedicled flaps or muscle versus fasciocutaneous flaps had a higher chance of hardware failure. A formal orthoplastic team was established in the period from 2017 to 2022, after which flap numbers were higher and hardware failure less for pedicled and fasciocutaneous flaps.

Conclusions

Pedicled flaps were associated with lower rates of hardware failure and infection requiring hardware removal. A formal orthoplastic team improves hardware-related outcomes.

Management of aseptic nonunions and severe bone defects: let us get this thing healed!

Effective nonunion and bone defect management requires consideration of multiple potential contributing factors including biomechanics, biology, metabolic, and patient factors. This article reviews these factors as well as several potential nonunion or bone defect treatments including bone grafts, bone graft substitutes, the induced membrane technique, and distraction osteogenesis. A summary of these concepts and guidelines for an overall approach to management are also provided.

A systematic review of the surgical outcomes of interprosthetic femur fractures

Background

Interprosthetic femur fractures (IFFs) are rare, but the treatment is challenging. Currently, there are many treatment methods used in practice, but an updated systematic review of comparison of common different surgical outcomes has not been thoroughly inspected.

Methods

A systematic review of retrospective studies was conducted. The resource databases of PubMed, Cochrane, and Embase were searched using a combination of the keywords involving IFFs and surgical outcomes from inception through June 2021. Data collected included patient demographics, intraoperative data, and postoperative outcomes. Outcomes were measured based on healing time, revision rate, complication rate, and functional scores.

Results

Forty studies were included for review with a total of 508 patients. Average reported age of patients was 78.7 years old and 403 (79.3%) were females. Overall union rate was 74.0% with 376 of 508 patients achieving fracture union after primary treatment of IFF. Only 271 patients had reported healing times of fractures with a mean of 5.15 months. The plate, prosthetic revision, nail/rod, and external fixator groups had mean healing times of 4.69, 8.73, 6.5, and 5.1 months, respectively. Revision rates were highest in the femur replacement treatment group with 9 (32.1%) patients needing at least one reoperation surgery for any reason. Overall, hardware failure and non-unions were the most reported complications in treatment of IFFs. Postoperative functional outcome scores were available for 242 patients. Harris Hip Scores for the plate, revision, replacement, nail/rod, and plate + revision groups were 76.84, 77.14, 69.9, 77, and 78.4, respectively.

Conclusion

Each treatment method should be carefully considered by the surgeon depending on the patient. Locking plate was the most common method for the treatment of the patients with IFFs. Half of them combined with cerclage wires/cables. Around two thirds' patients could achieve union with the fastest mean healing time around 4.69 months. Other less common methods included prosthetic revision, femur replacement, nail/rod, external fixator, etc. A small number of patients treated with Ilizarov external fixator, and it has proven to be a viable option with few complications and high union rates.

Therapeutic Efficacy and Safety of Osteoinductive Factors and Cellular Therapies for Long Bone Fractures and Non-Unions: A Meta-Analysis and Systematic Review

BACKGROUND

Long bone fractures display significant non-union rates, but the exact biological mechanisms implicated in this devastating complication remain unclear. The combination of osteogenetic and angiogenetic factors at the fracture site is an essential prerequisite for successful bone regeneration. The aim of this study is to investigate the results of the clinical implantation of growth factors for intraoperative enhancement of osteogenesis for the treatment of long bone fractures and non-unions.

METHODS

A systematic literature review search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the PubMed and Web of Science databases from the date of inception of each database through to 10 January 2022. Specific inclusion and exclusion criteria were applied in order to identify relevant studies reporting on the treatment of upper and lower limb long bone non-unions treated with osteoinductive or cellular factors.

RESULTS

Overall, 18 studies met the inclusion criteria and examined the effectiveness of the application of Bone Morphogenetic Proteins-2 and -7 (BMPs), platelet rich plasma (PRP) and mesenchymal stem cells (MSCs). Despite the existence of limitations in the studies analysed (containing mixed groups of open and close fractures, different types of fractures, variability of treatment protocols, different selection criteria and follow-up periods amongst others), their overall effectiveness was found significantly increased in patients who received them compared with the controls (I2 = 60%, 95% CI = 1.59 [0.99-2.54], Z =1.93, p = 0.05).

CONCLUSION

Administration of BMP-2 and -7, PRP and MSCs were considered effective and safe methods in fracture treatment, increasing bone consolidation, reducing time to repair and being linked to satisfactory postoperative functional scores.

Case report: Forearm infected non-united fracture managed with the Masquelet technique in a 71-year-old female patient

Infected non-union status post forearm fracture fixation is a challenge to treat and may be associated with unpredictable outcomes. The management of such a case involving a 71-year-old female suffering from Parkinson's disease is reported herein. The patient referred to our unit for a second opinion while she was under consideration for amputation at her local hospital. Utilising the two stage Masquelet technique successful limb salvage and excellent function were achieved.

Case report: Restoration of an open 12 cm femoral defect treated with the Masquelet technique in a 20-year-old polytrauma

Infected post-traumatic femoral defects are challenging to treat, and limited options exist. The case of a 20-year-old polytrauma male who sustained a segmental femur fracture involving the femoral neck, distal femur and an intermediate diaphyseal bone defect of 12 cm is presented. The patient declined a long-term frame in his femur. The 2-stage Masquelet procedure resulted in successful outcome with limb preservation.

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Femoral bone defects are challenging to treat.

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Patients do not tolerate bone transport well in this area.

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Successful management of a 12cm femoral bone defect is reported in a 20-year old patient using the Masquelet technique.

The induced membrane technique for the management of long bone defects

AIMS

The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT.

METHODS

A systematic search was performed in CINAHL, The Cochrane Library, Embase, Ovid MEDLINE, and PubMed. We included articles from 1 January 1980 to 30 September 2019. Studies with a minimum sample size of five cases, where the IMT was performed primarily in adult patients (≥ 18 years old), in a long bone were included. Multivariate regression models were performed on patient-level data to determine variables associated with nonunion, postoperative infection, and the need for additional procedures.

RESULTS

A total of 48 studies were included, with 1,386 cases treated with the IMT. Patients had a mean age of 40.7 years (4 to 88), and the mean defect size was 5.9 cm (0.5 to 26). In total, 82.3% of cases achieved union after the index second stage procedure. The mean time to union was 6.6 months (1.4 to 58.7) after the second stage. Our multivariate analysis of 450 individual patients showed that the odds of developing a nonunion were significantly increased in those with preoperative infection. Patients with tibial defects, and those with larger defects, were at significantly higher odds of developing a postoperative infection. Our analysis also demonstrated a trend towards the inclusion of antibiotics in the cement spacer having a protective effect against the need for additional procedures.

CONCLUSION

The IMT is an effective management strategy for complex segmental bone defects. Standardized reporting of individual patient data or larger prospective trials is required to determine the optimal implementation of this technique. This is the most comprehensive review of the IMT, and the first to compile individual patient data and use regression models to determine predictors of outcomes. Cite this article: Bone Joint J 2020;102-B(12):1723-1734.