Background

It is an accepted fact that Ilizarov frames are difficult to live with. Professionals advise patients that things get easier over time, but, there is little evidence to support this. This study examined the course of patient's self-reported anxiety and depression during treatment with an Ilizarov frame.

The purpose of the study was to retrospectively assess the patients treated to date with the vac ulta system using a technique of antibiotic instillation.

The vac ulta system is licensed for use with anti-septic instillation fluid but we have now treated a number of patients with antibiotic instillation under the guidance of the microbiology department. All patients being treated with the vac ulta system were included in the study. There were no exclusions. Pathology treated, infecting organism, antibiotic used and length of treatment were all recorded. Any antibiotic related complications were noted. Treatment was judged successful with resolution of presenting symptoms, normalization of inflammatory markers and three negative foam cultures.

There were 21 patients included in the study. There were 13 male and 8 female patients. Length of treatment ranged from 1 week to 10 weeks with a mean of 4.2 weeks. Follow up ranged from 1 month to 42 months with a mean follow up of 17.9 months

The most common pathogen was Staph. Aureus(11 cases). Enterobacter, ESBL, Strep. Milleri, MRSA and Citrobacter were also treated. Antibiotics instilled included flucloxacillin, meropenem, gentamicin, vancomycin, meropenem and teicoplanin. There were no antibiotic reactions/allergies. Pathologies treated included osteomyelitis, two stage amputations for infection, infected non-union and infected metalwork. Infection recurred in 2 of 21 patients (10%), with one recurring at 18 months and one at 2 years.

The 90% treatment success rate is highly encouraging in this notoriously difficult group of patients to treat. In this series vac instill was an effective treatment of infection and allows antibiotic treatment to be targeted to the infected tissues. There were no adverse reactions seen.

Larger series with longer follow up are no needed but we believe this technique is safe, successful and easily administered can be cautiously adopted on a wider basis.

The aim of the study is to evaluate how patients over 65 years of age cope with the Ilizarov method of treatment, compared with patients a decade younger.

Two age groups were selected, 50–65 years versus 65 years and over. 20 consecutive patients were recruited for each group. SF36 scores were completed pre-operatively, at 6 weeks post op and 6 weeks post frame removal. 41 patients were recruited in total.

Seven patients were lost to follow up – 2 died, 2 became too ill to continue with treatment, 3 did not complete the SF36. This left 34 patients.

T test was used to analyse the results.

Both age groups showed an equal and statistically significant drop in SF36 scores whilst the Ilizarov frame was on (p<0.01 for each group).

After frame removal, SF36 in the >65 group was not significantly different to pre-operative values.

In the younger group, SF36 after frame removal was still significantly lower than pre-operative values (p<0.01).

Age makes no difference in how patients cope with the ilizarov frame during treatment. Older patients have low pre-injury function levels, but appear to return to this level quickly after frame removal. Younger patients do not recover pre-injury function in 6 weeks after completion of treatment.

Ilizarov frame removal often occurs in the outpatient setting, and previous data has shown it can be a painful experience. Frames with a total of four or more olive wires or half-pins in combination yielded increased pain scores at frame removal.

Sublingual fentanyl provides rapid onset, short acting analgesia for painful procedures such as dressing changes in burns patients. We hypothesised that administration of sublingual fentanyl, prior to frame removal would improve patients' pain scores.

Twenty-one patients were given 100 mcg sublingual fentanyl prior to frame removal. Their pain scores were documented on an 11-point (0–10) numeric visual scale before, immediately after, 15 and 30 minutes after frame removal, and the following day. The same nurse specialist removed all the frames. Nitrous oxide was available for patients if they needed further analgesia.

The majority of frames were removed from tibia. The average patient age was 40.8 years. Each frame had a median of 9 wires (range 2–17), and 4 olives (2–8). Eight frames had half pins (range 1–4, median 2). Fourteen patients used nitrous oxide in addition to fentanyl.

Overall, the average pain score was 3.1. This peaked at 7.5 immediately after frame removal, but 15 minutes following removal the average was 2.5. Patients who had supplementary nitrous oxide had higher pain scores throughout (though not beforehand), although these differences were not statistically significant.

Four patients (19%) reported adverse effects following administration, but none required medical intervention.

Patients' pain scores averaged 2.52 within 15 minutes of removal, compared with 5.25 from our previous review. This suggests that fentanyl may be beneficial in frame removal, but our sample size was small, and more research is needed in this area.

One of the most challenging cases encountered by orthopaedic surgeons is chronic osteomyelitis. The mainstays of successful treatment include: radical debridement, stabilisation of the bone if necessary; control of infection and finally skin cover or closure.

Negative pressure dressings have been used for over 10 years in the treatment of acute and chronic wounds with recognised benefits. Topical negative pressure wound therapy with instillation of solution in the local area (VAC Instill Therapy System®) is a new device available in the armamentarium of a limb reconstruction surgeon. This device automatically delivers instillation fluid into the infected wound, where this fluid is held for a while before application of topical negative pressure. This cycle helps remove infectious material leading to clean closed moist environment for better wound healing.

Senior authors (MGD and SLR) have used this VAC Instill therapy in 10 cases of chronic osteomyelitis from April 2007 to November 2008. All patients have been included in this study. All patients had (thorough) bony and soft tissue debridement followed by application of VAC Instill therapy with local delivery of antibiotics.

All patients were male with mean age of 39 years (range 20–56 years). There were eight cases of tibial osteomyelitis, one distal radial and one calcaneal osteomyelitis. Most had mixed growth, with Staphylococcus being most common infecting organism. Average duration for VAC Instill therapy was 32 days (range 20–71 days). Average hospital stay was 33 days (range 15–85 days) and average time to wound closure was 39 days (range 19–90). There were two failures of treatment one later had Lautenbach procedure and other had below knee amputation.

We conclude that VAC Instill therapy is very successful in the management of chronic osteomyelitis. These are the only early results available in the literature. Further studies are needed to back these findings.