Treatment of chronic osteomyelitis with antibiotic-impregnated polymethyl methacrylate (PMMA) - the Cierny approach: is the second stage necessary?

Background

Chronic osteomyelitis is a challenge for orthopedic surgeons. Most patients with osteomyelitis receive two-stage management according to Cierny-Mader. The first stage includes radical debridement and insertion of an antibiotic-impregnated cement spacer (ACS) (beads, rods, nails, or blocks) into the bone defect. The second stage is performed 6–8 weeks later, when the spacer is removed and a cancellous autograft is placed within the bone defect. The possibility of ACS as definitive management for osteomyelitis, avoiding the second stage, is presented.

Methods

Sixteen patients with osteomyelitis received radical debridement and insertion of an ACS in all forms into the bone defect as a definitive management. In 8 patients, the tibia was infected, 4 had femur infection, 2 humerus, 1 fibula, and 1 ankle. The mean age at the time of the first stage of reconstruction was 49 years (range, 13–71 years). According to the Cierny-Mader classification, 1 patient was C-M IA, another was IB, 7 IIIA, 6 IIIB, and 1 was 4A. All B hosts had systemic illnesses. The mean follow-up period was 6 years (1.5–16 years).

Results

No patient exhibited radiographic evidence of excessive bone loss. Signs of recurrence of osteomyelitis were not noted in any of the patients, and no fractures had occurred by the last follow-up.

Conclusion

Our study suggests that a proportion of patients with planned retention of ACS appear to function well without requiring further surgical intervention, especially in elderly or vulnerable patients.

Pediatric Femoral Neck Fractures after Sliding in a Water Slide: A Case Report of Two Patients

Introduction

In contrast to adults, fractures of the neck of femur in children are relatively rare. The commonly described mechanism of injury is high energy trauma. Treatment options are almost always surgical. Prognosis, which entails relatively high rates of complications, varies with specific anatomic location, time to surgery, and reduction quality.

Case Report

We describe two cases of 10- and 12-year-old girls who suffered a fracture of the neck of the femur, Delbet Type II and Type III, respectively, due to a suspected hyper-abduction injury while sliding on a water slide. Both patients were treated surgically, with the younger one developing signs of femoral head avascular necrosis a year postoperatively.

Conclusion

Children with pain and an inability to bear weight after water sliding together with an adult companion at their backs should raise suspicion among medical staff of a femoral neck fracture. Prompt pediatric orthopedic consultation and treatment are needed in case of fracture diagnosis to reduce the risk of complications.

The Paley ilioischial limb modification of the Dega osteotomy

Background

We aim to describe a modified Dega osteotomy technique in detail, emphasizing its eventual advantages in comparison to the original Dega osteotomy and ‘San Diego’ modification. We also present our related literature review on various osteotomy techniques.

Methods

We reviewed the radiological indices of 27 dysplastic hips in 25 children with cerebral palsy and developmental dislocation of the hips (9 boys, 16 girls; mean age, 5 years) who underwent a modified Dega osteotomy according to Paley.

Results

Comparing the radiological indices results between our patients and those reported by the various authors in the literature, the data are almost identical.

Conclusions

The modified Dega osteotomy is the only technique wherein all two limbs of the triradiate cartilage are true, which becomes a single hinge where the osteotomy turns. Despite the similar results in the radiological indices between our patients and those in the literature, we still consider that the entire triradiate cartilage is a better hinge point for the iliac osteotomy. The difference between the osteotomy adopted in our institution and the modality described by most authors in the literature is that the latter mostly ignore or miss the ischial limb of the triradiate cartilage.

Fixator-Assisted Plating in Pediatric Supracondylar Femur Fractures

Purpose. Pediatric femoral supracondylar fractures are difficult to reduce by either closed or open reduction. The abnormal muscle forces around the knee tend to significantly displace the distal short metaphyseal fragment. We describe a novel technique utilizing the combination of a temporarily intraoperative external fixation in order to achieve and maintain the reduction followed by internal fixation. Method. Three male patients younger than 16 years of age were operated in our department. The fractures were defined as pathological in 2 patients. In order to facilitate and maintain fracture reduction, an external fixator was temporarily used intraoperatively; once the fractures were internally fixed, the fixator was removed. Results. Anatomical reduction was achieved in all patients. In an average follow-up of 2 years, all the fractures are solidly healed and the various bone lesions are healing. All patients have returned to regular physical activity. Conclusion. Difficult supracondylar femur fractures in children are easier to manipulate and reduce with the assistance of an intraoperative external fixator. Once the fracture is internally fixed and stable, the external fixator is removed.

Can a linear external fixator stand as a surgical alternative to open reduction in treating a high-grade supracondylar humerus fracture?

OBJECTIVE

High-grade pediatric supracondylar humerus fractures are commonly treated with closed reduction and internal fixation with percutaneous pinning. When this fails, open reduction followed by internal fixation is the widely accepted procedure of choice. Use of a lateral external fixator was recently described as an optional procedure, but evidence is scarce.

METHODS

We investigated the outcomes of upper limbs treated by either open reduction with internal fixation or closed reduction and external fixation.

RESULTS

Twenty-one patients completed the long-term follow-up; 11 underwent open reduction, and 10 underwent external fixation. Most patients in both groups reported excellent satisfaction. In both groups, the modified Disabilities of the Arm, Shoulder, and Hand score was extremely low and the average elbow range of motion was almost identical. Radiographic analysis consisting of Baumann's angle and the carrying angle revealed no statistical difference between the two groups.

DISCUSSION

Optional treatment using a linear external fixator for complex nonreducible supracondylar humerus fractures yielded acceptable clinical and radiographic results, as with open reduction. Our sample size was small, but the promising results may assist in the implementation of an alternative surgical procedure, especially in more complicated cases involving flexion-type fractures or severe soft tissue damage and swelling.

Outcomes of French's Corrective Osteotomy of the Humerus for Cubitus Varus Deformity in Children

BACKGROUND

Supracondylar humerus fractures are the most common elbow fractures in the pediatric population.

OBJECTIVES

To evaluate the outcomes of French's corrective osteotomy for correction of post-traumatic cubitus varus deformity in children.

METHODS

We conducted a retrospective review of medical charts of all patients who had undergone French's corrective osteotomy in our institution from 1998 to 2012. We recorded range of motion, cosmetic deformity, carrying angle, lateral cortex prominence index, hyperextension, and lateral cortex step before and after the surgery.

RESULTS

Seven patients were enrolled the study. Average follow-up time was 4.6 years (range 2-9 years). An average of 18.3º of limited flexion (range 5º-35º) compared to the healthy elbow was recorded in three patients. Lateral condylar prominence was recorded in one patient. The average preoperative carrying angle was -20.5º (range -15º-30º) and postoperative angle was 9.6º (range 7º-13º). In comparison, the average carrying angle in the healthy elbow was 8.5º (range 4º-13º). No lateral cortex prominence was recorded. An average of 27.5º (range 15º-35º) of hyperextension of the distal fragment was recorded immediately postoperatively in four patients; however, during postoperative follow-up, the hyperextension was corrected spontaneously in all patients.

CONCLUSIONS

As described by French, osteotomy has the ability to correct the varus deformity only in the coronal plane. However, our research supports the assumption that hyperextension in the sagittal plane might be corrected spontaneously.

Effect of skin surface temperature on skin pigmentation during contact and intralesional cryosurgery of keloids

BACKGROUND

This 15-month study was designed to compare the effect of skin surface temperature on skin pigmentation following a single intralesional or contact cryosurgical treatment of keloids.

PATIENTS/METHODS

Thirty Caucasian patients with 45 keloids present for more than 6 months were included in this study. Twenty-one keloids were treated by the contact method while the remaining 24 scars were managed using an intralesional cryosurgery technique. The skin surface temperature at the keloids was measured and recorded using a Ni/Cd thermocouple. Four variables of the thermal history were evaluated with the contact and the intralesional methods, namely cooling rate, hold time, end temperature and thawing rate. Assessment of the local hypopigmentation was performed 6 months after the treatment using a pigmentation scale.

RESULTS

Significantly slower cooling (6.09 +/- 4.56 degrees C/min) and thawing rates (54.52 +/- 32.17 degrees C/min) were recorded with the intralesional cryosurgery method when compared with the cooling rates (13.47 +/- 9.04 degrees C/min) and thawing rates (89.00 +/- 86.42 degrees C/min) of the contact method (P < 0.000001). The end temperature of the contact technique was significantly cooler (-46.77 +/- 14.74 degrees C) when compared with that of the intralesional method (-15.55 +/- 6.77 degrees C) (P < 0.000001). There was a trend for the hold time of intralesional cryosurgery to be longer (82.67 +/- 138.03 s) than that of the contact method (16.86 +/- 23.49 s) (P < 0.059). A significant difference in skin pigmentation was demonstrated between the two cryosurgical methods. In 91.7% of the keloids treated by the contact technique a significant hypopigmentation was noticed, while no marked hypopigmentation was detected in the skin surface of the keloids treated by the intralesional method (P < 0.0001).

CONCLUSION

We hypothesize that the thermal history of the skin surface during the intralesional cryosurgery technique provides a better survival environment for the melanocytes than the contact method, thus producing a lower rate of permanent hypopigmentation and disfiguring.