Aims. This study aimed to evaluate the effectiveness of the induced membrane technique for treating
Aims. The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of
Antibiotic-laden bone cement is an important strategy of treatment for an established bone infection. It was aimed to find the safe antibiotic dose intervals of the antibiotic cements soaked in Phosphate Buffered Saline solution and to determine whether there was a difference in terms of mechanical strength between the prepared samples. This study was done in our institute Microbiology and Metallurgy laboratories. All samples were prepared using manual mixing technique using 40 g radiopaque Biomet® Bone cement (Zimmer Biomet, Indiana, USA) under sterile conditions at 19 ± 2 ºC. In this study, vancomycin (4 groups − 0.5, 2, 4, 6 g), teicoplanin (4 groups − 0.8, 1.2, 2, 2.4 g), daptomycin (4 groups − 1, 2, 2.5, 3 g), piperacillin-tazobactam (4 groups − 0.125, 0.5, 1, 2 g) and meropenem (4 groups − 0.5, 2, 4, 6 g) were measured in a assay balance and added to the cement powder. Antibiotic levels ranged from the lowest 0.625% to the highest 15%. 80×10×4 mm rectangle prism-shaped sample for mechanical measurements in accordance to ISO 5833 standart and 12×6×1 mm disc-shaped samples for microbiological assesments were used. Four sample for each antibiotic dose and control group was made. Prepared samples were evaluated macroscopically and faulty samples were excluded from the study. Prepared samples were kept in Phosphate Buffered Saline solution renewed every 24 hours at 37 ºC. At the end of 6 weeks, all samples were tested with Instron ® 3369 (Norwood Massachusetts, USA) four point bending test. Staphylococcus aureus (ATCC 29213) strain was used for samples of antibiotics containing vancomycin, teicoplanin and daptomycin after the samples prepared for antibiotic release were maintained under sterile conditions and kept in Phosphate Buffered Saline solution as appropriate. For samples containing meropenem and piperacillin - tazobactam antibiotics, Pseudomonas aeruginosa (ATCC 27853) strain was used. The addition of more than 5% antibiotics to the cement powder was significantly reduced mechanical strength in all groups(p <0.05) however the power of significance was changed depending on the type of antibiotic. In general, adding antibiotics with 2.5% and less for cement amount was not cause significant changes in mechanical measurements. There was a negative correlation between the increase in the amount of antibiotics mixed with cement and the durability of the cement (p: <0.001, r: −0.883 to 0.914). In this study, especially the antibacterial effects of piperacillin-tazobactam, containing 0.25 gr and 0.5 gr antibiotic doses, were found to be low. There was no bacterial growth in all other groups for 21 days. Considering the mechanical properties of groups containing meropenem, vancomycin, daptomycin and teicoplanin, it was observed that all antibiotic cements remained above the limit value of 50 MPa in the bending test at concentrations containing 2.5% and less antibiotics. This was not achieved for the piperacillin-tazobactam group. The findings of the study showed that each antibiotic has different MPa values at different doses. Therefore, it could be concluded that not only the antibiotic dose but also the type oould change the mechanical properties. In the light of these findings, mixing more than 2.5% antibiotics in cement for the antibiotic types included in the study was ineffective in terms of antibacterial effect and mechanically reduces the durability of cement below the standard value of 50 MPa.
Introduction. Osteomyelitis is a challenge in diagnosis and treatment. 18F-FDG PET-CT provides a non-invasive tool for diagnosing and localizing osteomyelitis with a sensitivity reaching 94% and specificity reaching 100%. We aimed to assess the agreement in identifying the geographic area of
Aim.
Introduction. We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy. Materials & Methods. A systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing
In chronically infected fracture non-unions, treatment requires extensive debridement to remove necrotic and
Serial section electron microscopy (SSEM) was initially developed to map the neural connections in the brain. SSEM eventually led to the term ‘Connectomics’ to be coined to describe process of following a cell or structure through a volume of tissue. This permits the true three-dimensionality to be appreciated and relationships between cells and structures. The purpose of this study was to utilize this methodology to interrogate S. aureus
Treatment of bone infection often includes a burdensome two-stage revision. After debridement, contaminated implants are removed and replaced with a non-absorbable cement spacer loaded with antibiotics. Weeks later, the spacer is exchanged with a bone graft aiding bone healing. However, even with this two-stage approach infection persists. In this study, we investigated whether a novel 3D-printed, antibiotic-loaded, osteoinductive calcium phosphate scaffold (CPS) is effective in single-stage revision of an infected non-union with segmental bone loss in rabbits. A 5 mm defect was created in the radius of female New Zealand White rabbits. The bone fragment was replaced, stabilized with cerclage wire and inoculated with Staphylococcus aureus (MSSA). After 4 weeks, the
Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of
Prosthetic joint infection (PJI) is a complex disease that causes significant damage to the peri-implant tissue. Developing an animal model that is clinically relevant in depicting this disease process is an important step towards developing novel successful therapies. In this study, we have performed a thorough histologic analysis of peri-implant tissue harvested post Staphylococcus aureus (S. aureus) infection of a cemented 3D-printed titanium hip implant in rats. Sprague-Dawley rats underwent left hip cemented 3D-printed titanium hemiarthroplasty via posterior approach under general anesthesia. Four surgeries were performed for the control group and another four for the infected group. The hip joint was inoculated with 5×10. 9. CFU/mL of S. aureus Xen36 prior to capsule closure. The animals were scarified 3 weeks after infection. The femur was harvested and underwent micro-CT and histologic analysis. Hematoxylin and eosin (H&E), as well as Masson's trichrome (MT) stains were performed. Immunohistochemistry (IHC) using rabbit antibody for S. aureus was also used to localize bacterial presence within femur and acetabulum tissue . The histologic analysis revealed strong resemblance to tissue changes in the clinical setting of chronic PJI. IHC demonstrated the extent of bacterial spread within the peri-implant tissue away from the site of infection. The H&E and MT stains showed 5 main features in
Background and aim. In 2019, specific diagnostic and antibiotic treatment recommendations for diabetic foot infection (DFI) and osteomyelitis (DFO) were introduced in our institution. They include principles on numbers of biopsies to obtain for microbiological/histopathological examinations, labeling anatomic localization, and antibiotic treatment (ABT) duration based on the aforementioned findings. ABT should be stopped after complete resection of
Introduction and Objective. Management of bone loss associated with bone contamination or infection represents a double biological and clinical challenge frequent in traumatology. The advent of new biomaterials can allow a different approach in the treatment of bone gap. The purpose of this study was to evaluate the prophylactic and therapeutic effectiveness of addition of a new absorbable bone substitute (BS) eluting different antibiotics in reconstruction of bone defects after infections and fractures with soft tissue damage. Materials and Methods. We conducted a review of patients with contaminated or
Intro. Calcium sulphate (CS) is a recent alternative for antibiotic elution in
Aim. Chronic osteomyelitis (OM) is usually treated with surgical excision of
Aim. Infections in long bones can be divided in osteitis, osteomyelitis and septic non-unions. All are challenging situations for the orthopaedic surgeon. Treatment is a mix with debridement, radical resection of infected tissue, void filling with different types of products, and antibiotic therapy of different kinds. In cavitary bone defects, bioglasses such as BAG-S53P4 have given good results in early or mid-term follow-up. Results of such treatment in segmental bone defects remain unknown. The goal of our study was to evaluate efficacity of active bioglass BAG-S53P4 in septic segmental bone defects. Method. A retrospective cohort study has been done in a single specific orthopaedic center devoted to treatment of infected bony situations. All cases were a severe septic bone defect. We have compared the segmental bone defects to the cavitary ones. Results were analyzed on recurrence of infection, bone healing, functional result and complication rate. Results. 14 patients were included with a minimum follow-up of 1 year after treatment. 8 were in the group “cavitary”, 6 in the group “segmental”. The mean age was 54 years-old (30–76). Sex-ratio was 2.5. All patients have been treated with bone resection and debridement of
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. 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.Aims
Methods
Aim. Local concentration of antibiotic at the site of infection is a major parameter for its efficiency. However, bone diffusion is poor leading either to their non-use (ex: gentamicin) or the use of high concentration (ex: vancomycin). Local administration could optimize their local concentration combined with lower side effects. We report the clinical experience and pharmacological results of an antibiotic loaded porous alumina used to replace
Aims. Chronic osteomyelitis may recur if dead space management, after
excision of
The February 2023 Trauma Roundup360 looks at: Masquelet versus bone transport in infected nonunion of tibia; Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multicentre randomized clinical trial; Is the T-shaped acetabular fracture really a “T”?; What causes cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures?; Is the common femoral artery at risk with percutaneous fragility pelvis fixation?; Anterior pelvic ring pattern predicts displacement in lateral compression fractures; Differences in age-related characteristics among elderly patients with hip fractures.
The August 2024 Foot & Ankle Roundup360 looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.
The management of periprosthetic joint infection (PJI) remains a major challenge in orthopaedic surgery. In this study, we aimed to characterize the local bone microstructure and metabolism in a clinical cohort of patients with chronic PJI. Periprosthetic femoral trabecular bone specimens were obtained from patients suffering from chronic PJI of the hip and knee (n = 20). Microbiological analysis was performed on preoperative joint aspirates and tissue specimens obtained during revision surgery. Microstructural and cellular bone parameters were analyzed in bone specimens by histomorphometry on undecalcified sections complemented by tartrate-resistant acid phosphatase immunohistochemistry. Data were compared with control specimens obtained during primary arthroplasty (n = 20) and aseptic revision (n = 20).Aims
Methods
This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification. We conducted a retrospective analysis of 162 knees (162 patients) that received treatment for PJI post-TKA with combined IV and topical antibiotic infusions at a single academic hospital from 1 January 2010 to 31 December 2022. The incidence of AKI was evaluated using the KDIGO criteria, focussing on the identification of significant predictors and the temporal pattern of AKI development.Aims
Methods
Aim. Antibiotic-loaded biomaterials are often used in dead space management after excision of
Aim. The aim of this work was to evaluate, via foot and ankle TC scans, the outcomes of the use of a bone substitute (CERAMENT|™G) and the growth of native bone in the treatment of osteomyelitis (OM) of the diabetic foot. Method. In nine patients from July 2014 to December 2016 we used a Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in OM diabetic foot cases. Of these nine patients, three were female and six were male and their ages were between 49 and 72 years. Four patients had hindfoot involvement and underwent partial calcanectomy. Two patients presented a rocker-bottom Charcot foot pattern III according to Sanders and Frykberg's classification and were treated with esostectomy of the symptomatic bony prominence of the midfoot. One patient presented OM of the 3°, 4° and 5° metatarsal bones. One patient underwent partial resection of the midfoot and hindfoot with arthrodesis stabilised by an internal-external hybrid fixator. One patient with a Charcot foot pattern IV-V underwent partial talectomy and calcanectomy with arthrodesis stabilised by an internal-external hybrid fixator. In all these patients - after removal of the
Aim. Simultaneous use of Ilizarov techniques with transfer of free muscle flaps is not current standard practice. This may be due to concerns about duration of surgery, clearance of infection, potential flap failure or coordination of surgical teams. We investigated this combined technique in a consecutive series of complex tibial infections. Method. A single centre, consecutive series of 45 patients (mean age 48 years; range 19–85) were treated with a single stage operation to apply an Ilizarov frame for bone reconstruction and a free muscle flap for soft-tissue cover. All patients had a segmental bone defect in the tibia, after excision of
Surgical treatment of
Antibiotic concentration in
Restoration of the bone defects on the background of the purulent osteomyelitis process is one of most pressing problems in orthopedics. In the last few years the medical procedure was improved thanks to use of semi-synthetic or syntetic implantation biodegradable composite materials. The object of the investigation is to study possibilities of use of fast-biodegradable implant LitAr (Russia) for filling
Periprosthetic joint infection (PJI) occurs in approximately 1% to 2% of total knee arthroplasties (TKA) presenting multiple challenges, such as difficulty in diagnosis, technical complexity, and financial costs. Two-stage exchange is the gold standard for treating PJI but emerging evidence suggests 'two-in-one' single-stage revision as an alternative, delivering comparable outcomes, reduced morbidity, and cost-effectiveness. This study investigates five-year results of modified single-stage revision for treatment of PJI following TKA with bone loss. Patients were identified from prospective data on all TKA patients with PJI following the primary procedure. Inclusion criteria were: revision for PJI with bone loss requiring reconstruction, and a minimum five years’ follow-up. Patients were followed up for recurrent infection and assessment of function. Tools used to assess function were Oxford Knee Score (OKS) and American Knee Society Score (AKSS).Aims
Methods
Aims: Purpose of this study was to evaluate the results of a staged revision technique in the treatment of deep infection after limb salvage surgery for bone tumors and to identify factors possibly affecting the outcome. Methods: A retrospective study of 19 consecutive patients with an
In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF. From April 2013 to May 2017, 46 consecutive patients with SSI post-ORIF for TPFs were managed in our centre with an induced membrane technique. Of these, 35 patients were included for this study, with data analyzed in a retrospective manner.Aims
Methods
Bone infection occurring after fractures or orthopedic surgery can progress to the chronic stage and lead to poor results of treatment. Optimal treatment of chronic osteomyelitis are stabilization the fracture, biological recovery of bone defects and destroy bacterial infection. Traditional methods of treatment are systemic administration of antibiotics and surgical treatment of active infection focus. Systemic antibiotics are part of the standard therapy after surgical treatment of
Introduction. Septic knee arthritis with severe osteoarthritis (OA) presents challenging clinical situations because of unexpected and long time for treatment and less satisfactory clinical outcomes. Septic arthritis with damage to articular cartilage developed osteomyelitis (OM) frequently. Although arthroscopic debridement was the common treatment of septic arthritis, there was some limitation on the management of
Bone and joint infections of the lower limbs cause significant morbidity for patients. Infection is a devastating complication for prosthetic joint replacements. In this large case series from a single centre in the NE of England, we present our experience of using antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 for local elution of antibiotics at the site of infection. At our centre, from August 2012 to Jan 2015, antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 was used for local elution of antibiotics in 45 patients with lower limb bone or joint infections. Tailored plans were made by Orthopedic surgeon and Microbiologist MDTs based on bacteria and sensitivities. Cases included 20 THR, 13 TKR, 5 Hemiarthroplasties, 4 tibial nonunions, 1 infected femoral plate and 2 paediatric osteomyelitis. Organisms isolated – Coagulase negative Staphs, Staph aureus, MRSA, E coli, Enterococcus, Enterobacter cloacae, Serratia and 1 Salmonella typhimurium!!. In our cases, a combination of Vancomycin and Gentamicin was added to Stimulan beads following manufacturer's mixing guide. In 2 cases, we added Ceftazidime to the beads and Daptomycin in 1 case. In bone infections, surgical debridement and systemic antibiotics were also needed. All arthroplasty infections underwent explantation with addition of antibiotic impregnated beads either at single stage or both stages of 2 stage revisions and systemic antibiotics. Follow up (ranging 9months to 2 years) indicates no failure so far. The beads caused no excessive wound drainage. There was no need to remove beads as they dissolve. In the cases where a staged revision was performed, the beads were inserted at first stage and there was microbiological clearance of infection at 2nd stage. Our series includes some experince in paediatric cases too. As far as we are aware, this is the largest series in the UK from a single centre reporting experience with Stimulan in
Aim of this work was to evaluate the efficacy of a new antibiotic bone substitute (CERAMENTTM|G) in the treatment of osteomyelitis (OM) in diabetic foot. From June 2013 to April 2015 we used a new Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in cases of diabetic foot OM. The uniqueness of this product is that it induces native bone growth, while the synthetic bone disappears and antibiotic is released into the surrounding tissues, maintaining high gentamicin concentrations for some weeks. In 20 patients, with or without Charcot neuroarthropathy and post-lesional osteomyelitis, after removal of
Infected nonunion of the femur or tibia diaphysis requires resection of
Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics. Cite this article:
The management of post-traumatic bone infections relies on antibiotic therapy and surgical debridement. Antibiotic concentration in
The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device. This is a retrospective review of prospective data collected on all patients treated in our institution using this implant. We report the demographics, nail accuracy, reliability, consolidation index, and cases where concerning clinical and radiological findings were encountered. There were 14 STRYDE nails implanted in nine patients (three male and six female) between June 2019 and September 2020. Mean age at surgery was 33 years (14 to 65). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies.Aims
Methods
Background:. Wide resection of
To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes. A review of the medical records was conducted of consecutive 35 lower limbs (30 males and five females; median age 46 years (interquartile range (IQR) 40 to 61)) treated with IMT using β-TCP between 2014 and 2018. Lower Extremity Functional Score (LEFS) was examined preoperatively and at final follow-up to clarify patient-centered outcomes. Bone healing was assessed radiologically, and time from the second stage to bone healing was also evaluated. Patients were divided into ≥ 50 mm and < 50 mm defect groups and into femoral reconstruction, tibial reconstruction, and ankle arthrodesis groups.Aims
Methods
Aim. Previous studies of primary internal fixation of infected non-unions have reported high failure rates. Local antibiotic carriers and coatings have been advocated to reduce infection around implants and allow bone healing. We evaluated the effect of a calcium sulphate/hydroxyapatite antibiotic-loaded composite on bone healing and the eradication of infection in combination with internal fixation. Method. Twelve cases of established infected non-union, with segmental bone loss of up to 1cm were treated using a multidisciplinary protocol. This included; excision, deep sampling, stabilisation, local and systemic antibiotics, and soft-tissue closure. We treated 5 femurs, 4 humeri, 1 tibia and 2 periarticular non-unions at the ankle. Mean age was 59.8 years (34–75) and 9 patients had systemic co-morbidities (C-M Type B hosts). 9 patients had single stage surgery, with 5 IM Nails and 4 plates. Three patients had planned second stage internal fixation after external fixation to correct deformity. Staph. aureus was the commonest pathogen (5 cases) with polymicrobial infection in 3 cases. Results. All 12 patients were infection-free at a mean follow-up of 23 months (range 13–34 months). Union was achieved in 11/12 (92%) with the primary surgery alone. The single failure was the tibial case, who remains with an infection-free, stiff non-union. Conclusion. This protocol offered good results, mainly with a single stage treatment. Primary internal fixation was possible in 9 cases, without recurrent infection. The combination of excision of
Treatment of chronic osteomyelitis (COM) for young patients remains a challenge. Large bone deficiencies secondary to COM can be treated using induced membrane technique (IMT). However, it is unclear which type of bone graft is optimal. The goal of the study was to determine the clinical effectiveness of bone marrow concentrator modified allograft (BMCA) versus bone marrow aspirate mixed allograft (BMAA) for children with COM of long bones. Between January 2013 and December 2017, 26 young patients with COM were enrolled. Different bone grafts were applied to repair bone defects secondary to IMT procedure for infection eradication. Group BMCA was administered BMCA while Group BMAA was given BMAA. The results of this case-control study were retrospectively analyzed.Aims
Methods
Implant materials impregnated with antibiotics have long been used to manage the dead space created by debridement surgery in patients with osteomyelitis. To present our preliminary results and in vivo response of patients to PerOssal used to treat bone infection in the form of long bone chronic osteomyelitis. PerOssal is a new osteoconductive bone substitution material for bone filling which consists of an entirely synthetically produced, nanocrystalline hydroxyapatite and calcium sulfate. It can be used effectively as a local antibiotic carrier for the reconstruction of
Introduction: Arthrodesis of the knee nowadays is used as a salvage procedure, commonly for patients with a failed TKR or in infected trauma cases. We present 4 patients with extensive bone defects following septic sequelae of trauma treated by Arthrodesis of the knee joint. Materials and Methods: Four patients (avg. 46.5 years; range 37–57 years; three male and one female) with longstanding infected non-union fractures (3 months–2 years) at the knee joint (three Tibial plateau and one distal femur) were treated by initial debridement and removal of dead or
Subacromial corticosteroid injections are a well-recognised management for chronic shoulder pain and are routinely used in general practice and musculoskeletal clinics. Mycobacterium tuberculosis (TB) of a joint is a rare presentation in the United Kingdom. International literature exists for cases of reactivated latent tuberculosis following intra-articular corticosteroid injections in a knee; however there are no reports of a primary presentation of undiagnosed TB in a joint following therapeutic corticosteroid injections. A seventy-four year old lady presented with a one-year history of a painful shoulder, which clinically manifested as a rotator cuff tear with impingement syndrome. Following three subacromial depo-medrone injections, the patient developed a painless “cold” lump which was investigated as a suspicious, possibly metastatic lesion. This lump slowly developed a sinus and a subsequent MRI scan identified a large intra-articular abscess formation. The sinus then progressed to a large intra-articular 5×8 cm cavity with exposed bone (picture available). The patient had no diagnosis of TB but had pathogen exposure as a child via her parents. The patient underwent three weeks of multiple débridement and intravenous amoxicillin/flucloxacillin to treat Staphylococcus aureus grown on an initial culture. Despite best efforts the wound further dehisced with a very painful and immobile shoulder. Given the poor response to penicillin and ongoing wound breakdown there was a suspicion of TB. After a further fortnight, Mycobacterium tuberculosis was eventually cultured and quadruple antimicrobial therapy commenced. Ongoing débridement of the rotator cuff and bone was required alongside two months of unremitting closed vacuum dressing. The wound remained persistently open and excision of the humeral head was necessary, followed by secondary wound closure. There were no extra-articular manifestations of TB in this patient. At present the shoulder is de-functioned, the wound healed and shoulder pain free. This unique case study highlights that intra-articular corticosteroid can precipitate the first presentation of Mycobacterium tuberculosis septic arthritis. The evolution of symptoms mimic many other shoulder complaints making confident diagnosis a challenge. The
K. Kuršumović, C. P. Charalambous. Graft salvage following
Introduction: Implant materials impregnated with antibiotics have long been used to manage the dead space created by debridement surgery in patients with osteomyelitis. Purpose: To present our preliminary results and in vivo response of patients to PerOssal used to treat bone infection in the form of long bone chronic osteomyelitis. PerOssal is a new osteoconductive bone substitution material for bone filling which consists of an entirely synthetically produced, nanocrystalline hydroxyapatite and calcium sulfate. It can be used effectively as a local antibiotic carrier for the reconstruction of
We report our experience in treating victims of the recent Earthquake Disaster in Pakistan. Our experience was based on 2 humanitarian missions to Islamabad. First in October 2005, 16 days after the earthquake and the second in January 2006, three months later. The mission consisted of a team of orthopaedic and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov External Fixators (IEF). We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad. During the first visit we treated 12 injured limbs in 11 patients. 7 of these were children (ages 6 – 14). All the cases were complex and severe multifragmentary fractures associated with crush injuries. All of the fractures involved the tibia, which were treated with IEF. Nine fractures were type 3b open injuries. Eight were infected requiring debridement of
Introduction: Arthrodesis of the knee nowadays is used as a salvage procedure, commonly for patients with a failed TKR or in infected trauma cases. We present 4 patients with extensive bone defects following septic sequelae of trauma treated by Arthrodesis of the knee joint. Materials and Methods: Four patients (avg. 46.5 years; range 37–57 years; three male and one female) with longstanding infected non-union fractures (3 months–2 years) at the knee joint (three Tibial plateau and one distal femur) were treated by initial debridement and removal of dead or
We treated 37 patients with chronic osteomyelitis of the tibia (25), femur (9), radius (2) and humerus (1) by a two-stage technique, comprising radical debridement of all
Bioactive glasses (BAGs) are bone substitutes with bone bonding, angiogenesis promoting and antibacterial properties. The bioactive process leading to bone bonding has been described as a sequence of reactions in the glass and at its surface. Implantation of the glass is followed by a rapid exchange of Na+ in the glass with H+ and H3O+ from the surrounding tissue, leading to the formation of silanol (SiOH) groups at the glass surface. Due to migration of Ca2+ and PO43− groups to the surface and cystallization, a CaO-P2O5 hydroxyapatite (HA) layer is formed on top of the Si-rich layer. Finally, cell interactions with the HA layer subsequently initiate the bone forming pathway. The rapid increase in pH and the subsequent osmotic effect caused by dissolution of the glass have been suggested to partly explain the antibacterial properties observed for BAGs. Comparing bactericidal effects of different BAGs, BAG-S53P4 has been shown to be the most effective, with the fastest killing or growth inhibitory effect. This antibacterial effect has been observed in vitro for all pathogens tested, including the most important aerobic and anaerobic pathogens, as well as very resistant bacteria. In a multicentre study in 2007–2009, BAG-S53P4 was used as bone graft substitute in treatment of osteomyelitis. Eleven patients (nine males, two females) with a radiologically diagnosed osteomyelitis in the lower extremity (N=10) and in the spine (N-1) participated. In the operation, the
Purpose of the study: Arthrodesis is the treatment of choice for advanced-stage infection involving the tibiotarsal joint. In aseptic conditions, clinical and biomechanical experiments have shown that internal fixation can lead to a better rate of bone fusion. In septic conditions, external fixation, or a hybrid system, is preferred by many authors. The purpose of this retrospective study was to report the outcomes obtained with tibiotarsal arthrodesis with exclusive internal fixation in a septic environment. Material and methods: From March 1992 to October 2005, twenty patients underwent tibiotarsal arthrodesis for the treatment of septic arthritis, 18 in a one-phase procedure and two in a two-phase procedure with bone graft. The series included four women and 16 men, mean age 50±15 years. The joint lesions were posttraumatic in 15 cases, related to primary osteonecrosis of the talus in one and to primary arthritis in four. Mean duration of the infection was 2.5 years. Resection of
1. A technique of closed instillation-suction for the treatment of chronic bone infection is described in which
This study presents patient-reported quality of life (QoL) over the first year following surgical debridement of long bone osteomyelitis. It assesses the bone involvement, antimicrobial options, coverage of soft tissues, and host status (BACH) classification as a prognostic tool and its ability to stratify cases into ‘uncomplicated’ or ‘complex’. Patients with long-bone osteomyelitis were identified prospectively between June 2010 and October 2015. All patients underwent surgical debridement in a single-staged procedure at a specialist bone infection unit. Self-reported QoL was assessed prospectively using the three-level EuroQol five-dimension questionnaire (EQ-5D-3L) index score and visual analogue scale (EQ-VAS) at five postoperative time-points (baseline, 14 days, 42 days, 120 days, and 365 days). BACH classification was applied retrospectively by two clinicians blinded to outcome.Aims
Methods
1. One hundred and one cases of cancellous chip bone grafting operations for filling of
Summary Statement. A single, locally-delivered injection of a human placental product containing multipotent stromal cells reduced severity of infection in an immunosuppressed murine osteomyelitis model and eliminated infection in 25% of animals compared with 0% of controls without the use of antibiotics. Introduction. Implant–associated osteomyelitis is a serious orthopaedic condition and is particularly difficult to treat in immunosuppressed individuals. Despite great advancement in the field of biomaterials and pharmaceuticals, emerging patterns of antibiotic resistance, complex biofilm production and penetration of therapeutic concentrations of effective antibiotics into bone continue to represent unmet clinical challenges. The promise of adult multipotent stromal cells (MSCs) for tissue regeneration has been of intense interest in recent years. Among their many potential therapeutic uses, MSCs have also been shown to have direct antimicrobial properties. The objective of this study was to evaluate the efficacy of a locally–delivered human placental-based tissue product containing multipotent stromal cells (hAmSC) to reduce the severity of implant-associated Staphylococcus aureus osteomyelitis in an immunosuppressed murine model. We hypothesised that athymic mice with implant-associated osteomyelitis would have diminished infection following treatment with hAmSC as evidenced by decreased bioluminescence intensity and lower histologic scores for infection and bacterial load when compared to saline-treated controls. Methods. An athymic murine model of chronic implant-associated osteomyelitis was developed using luciferase-transfected Staphylococcus aureus to study the antimicrobial effects of a human placental-based product containing multi-potent stromal cells (hAmSC). Sixteen athymic mice had osteomyelitis established in the right femoral diaphysis. Fifteen days after inducing luc S. aureus osteomyelitis, the mice were randomised to receive a single 0.5 cc injection of hAmSC (n=8) or vehicle (0.9% saline) (n=8) into the soft tissues immediately adjacent to the
Different conditions may lead to bone loss in bone infections. Septic non-unions, osteomyelitis, septic joint prosthesis are all conditions that may be associated with the need for bone grafts and/or of bone substitutes. The risk of infection recurrence makes, in these cases, particularly challenging the choice of the type of bone implant. The use of growth factors, eventually associated with autologous or homologous bone grafts or with bone substitutes, may be helpful in restoring the bone stock, allowing to fill large bone defects, once the infection is controlled. We present the preliminary results in 10 patients in which autologous Platelet Rich Plasma (PRP) has been used to treat large bone defect in two stage hip reconstruction (7 cases) and in previously infected non-unions (3 patients). At a minimum follow-up of 6 months (maximum 18 months) a significant new bone formation occurred at the site of PRP application in all the cases treated and no signs of infection recurrence are present at the time of writing. This is the first report on the short-term safety of use of PRP for the treatment of bone loss in previously
Bacteriophage state currently an attractive alternative for antibiotics, especially due to the strong in vitro activity and lack of side effects. Eight patients with chronic infection in musculoskeletal system.are presented. This group includes: 3 cases of deep periprosthetic infection, posttraumatic osteomyelitis of tibia in 2 cases, infected pseudoarthrosis of femur in 1 case, chronic hematogenous osteomyelitis of tibia in 1 case, chronic infection in diabetic foot in 1 case. Adequate tissue specimen for bacteriology was taken during operation and selection of bacteria strains was subsequently done and appropriate phage were cultured. Phage were taken orally by patients 4–6 weeks after operation. Despite of paralel phage and systemic antibiotic administration all patients underwent operative debridement of
Introduction: Osteomyelitis often causes functional impairment due to tissue destruction and the incidence of this condition appears to be increasing. Antimicrobial peptides (AP) are effectors of the innate defence system and play a key role in host protection at cellular surfaces. Human beta-defensins (HBD) represent a major subclass of antimicrobial peptides and act as a first line defence through their broad spectrum of potent antimicrobial activity (1). The aim of the present in vitro and in vivo investigations was to study the expression and regulation of HBD-2 and -3 in the case of bacterial bone infection and to analyze the effects of immunosuppressive drugs on bone-derived AP-expression. Methods: Samples of healthy human bone, osteomyelitic bone and cultured osteoblasts (primary-, hFOB- and SAOS-2 cells) were assessed for the expression of HBD-2/-3 by RT-PCR, immunohistochemistry or ELISA. Regulation of HBD-2/-3 was studied after exposure to Staphylococcus aureus (SAS) or Pseudomonas aeruginosa (PAS), proinflammatory cytokines (IL-1, 10ng/ml) and immunosuppressive drugs (glucocorticoids, methotrexate) and was assayed by ELISA. An osteomyelitis mouse model was performed to demonstrate the regulation of the murine homologues of HBD-2/-3 by real time RT-PCR and immunohistochemistry. Results: ELISA experiments demonstrated, that samples of
Purpose: A clinical retrospective study of surgical treatment of chronic posttraumatic osteomyelitis by the Ilizarov method was conducted by analyzing the end results.The aim was to evaluate the efficacy of distraction osteogenesis in covering large bone defects and eradicate infection. Materials and method: Between 1990–2000, twenty-one patients with chronic osteomyelitis were surgically treated. Inclusion criteria were: 1) active infection of more than six months and 2) bone defect (after the surgical debridement was completed) >
4cm.The average length of bone defect was 9,5 cm. (4–28cm.). In all cases corticotomy and application of the Ilizarov device was necessary to initiate bone transport.The protocol of the Association for the Study and Application of the Method of Ilizarov (A.S.A.M.I), was used to evaluate the results. All patients were examined clinically and radiographically in order to assess the proper alignment, the progress of bone healing and possible signs of infection. Result: Thirteen patients (62%) presented delayed union at the docking site. In 4 patients compression –distraction was necessary to promote union. In 9 patients (43%) the Ilizarov device was removed and interlocked intramedullary nailing was performed after eradication of the infection was confirmed by clinical and laboratory data. Recurrence of infection occurred in one patient. Elimination of infection and solid bone formation was the end result for all patients. Two refractures at the docking site needed reapplication of an Ilizarov device. In one case angular deformity of more than 10 degrees needed correctional osteotomy. Conclusions: The Ilizarov method addresses successfully infection, bone defect, deformity, and leg length discrepancy simultaneously. All these may coexist in difficult cases of chronic osteomyelitis. Complications associated specifically with bone transport in exceeded bone defects ,after radical resection of
Introduction: Reports about the usefulness of FDG-PET in detecting infections were few in the last years but are greatly increasing in number in the recent years. The interest for this method is related to the demonstration that FDG uptake is increased in cells with elevated glycolitic activity as neoplastic cells, neutrophils, activated macrophages, probably bacteria. As far as a neoplasm is excluded, FDG uptake is increased in inflammatory sites. This study was done to test the possible use of this method in painful total hip-replacement diagnosis. Materials and methods: A prospective study on 24 patients (33 hip arthroplasties) affected by painful total hip replacement was conducted. All patient has blood test, X-ray examinations of hips and chest, Ultrasound scan, cultures from sinus tract or hip aspiration, Tc. 99m. MDC bone scan (SPECT), FDG-PET. Areas of uptake were evaluated and compared. Fifteen patients were operated on (9 two-stage revisions, debridements), during operation cultures were repeated and bone biopsy were done at the sites of icreased PET uptake. Bone and soft tissue debridement was specifically performed on site of PET uptake with maximal preservation of bone stock. Results: Infected hips were 20. Infection was demonstrated by positive culture and positive biopsy in all cases. Sensibility and specificity of PET were respectively 100% and 92%. The study of tracers uptake showed that these are complementary and give different information. All patients who were operated on were reviewed with a mean follow up of 7 months (range 3 months-15 months ). The nine patients who had revision were free of infection at follow-up. Discussion: from our experience PET is easy to perform, has an excellent sensibility and good specificity and can be placed at the end point of the flow-chart for diagnosis of total hip replacement infection (preceeded in any case by standard X-Rays and bone scan). Moreover PET scan could be useful in pre-operative planning of revision surgery as it has better anatomical definition than traditional scans and may allows surgeon to localize on three planes
Introduction: Intramedullary reaming has its selected indication in osteomyelitis of long bones when remnants of dead
Introduction: The bone defects in the long bones are traumatic as a consequence of open fractures or resections due to infection or necrotic nonunion. A devitalised bone with no nutrition or vascularity is liable to an infection, with extension proportional to the size of the necrotic bone. To be sure to eliminate the infection and the nonunion it is necessary to perform open surgery and remove the necrotic and infected segments thoroughly, and then proceed to osteosynthesis and internal transport after osteotomy. Material and Methods: From 1981 to 2002 203 cases were treated with the Ilizarov Method. The previous treatment given before the patients came to our center was as follows: 1) in tibial nonunion intramedullary nail 17%; 2) in femoral nonunion plates 46%, monoaxial external fixator 42%, intramedullary nail 10%, circular external fixator 4%; 3) humerus nonunion Ender 3%, plates 81%, intramedullary nail 16%; 4) forearm nonunion plates 80%, wires and cast 20%. Our treatment was resection of the
Septic arthritis of the shoulder or an infected arthroplasty are rare events, but when they do occur present difficult clinical challenges. Little can be found in the existing literature to provide guidance in managing these problems. Certainly early signs of infection are best treated aggressively with irrigation, debridement and appropriate intravenous antibiotic therapy. Early aggressive management can sometimes prevent formal septic arthritis, when a prosthetic implant is well seated may preclude development of deep infection and need for removal. However, in the face of definitive septic arthritis or sepsis around a prosthetic shoulder implant, aggressive debridement including removal of
Methicillin– resistant Staphylococcus aureus (MRSA) infected gap non –union of long bones fractures is a challenge to manage. Treatment options are limited such a Ilizarov bone transport, vascularized bone free transfer etc. These techniques have complications and require expertise. We present a rare case with MRSA infected nonunion and bone defect 5cm of ulna which was managed with the induced membrane formation. A 33-years old male presented to outpatient department, 2 months after internal fixation on both left bone forearm fractures (Gustillo I). There was pus discharge from the operative site of ulna. Culture results: MRSA, C-Reactive Protein (CRP): 2,58 (0–5), Erythrocyte Sedimentation Rate (ESR): 42 (0–20). Intravenous (iv) Teicoplanin and Rifampicin were administrated and after one month no topic symptoms and CRP- ESR were normal. One month later he had again actively draining sinus (CRP: 1,47 ESR:22). The implant (ulna) was removed and a gap 5 cm was created at the fracture site (necrotic-infected bone debrided), which was filled by cemented spacer (Tobramycin and vancomycin). An external fixator was applied to ulna. Radius was not involved. Post op. iv the same antibiotics for 4 weeks. At the end of 8 weeks, the spacer was removed and the gap was filled with autologous cancellous bone graft (iliac crest). After 5 months the patient was reviewed. No any clinical and functional problems. Radiographics and CT-images were showed osseous consolidation. This technique (called as ‘Masquelet’) gives promising result in the management of
To characterize the intracellular penetration of osteoblasts and osteoclasts by methicillin-resistant Time-lapse confocal microscopy was used to analyze the interaction of MRSA strain USA300 with primary murine osteoblasts and osteoclasts. The effects of early and delayed antibiotic treatments on intracellular and extracellular bacterial colony formation and cell death were quantified. We tested the effects of cefazolin, gentamicin, vancomycin, tetracycline, rifampicin, and ampicillin, as well as agents used in surgical preparation and irrigation.Aims
Methods
Purpose of the study: Brodie abscess is a purulent collection in the centre of a bone separated in its typical form from soft tissue by an impermeable barrier of compact bone tissue. This “trapped” collection causes a clinical syndrome of pain and infection. Lat diagnosis is frequent after the symptoms have evolved over months or years. The purpose of our work was to illustrate the misleading features of this bone infection using a series of 11 periarticular localisations of Brodie abscess. Material and methods: Our study included ten patients, mean age 18 years, who were treated over a period of six years. One patient had a double localisation. The main foci were the distal femur (n=4) and the upper tibia (n=4). There was one case involving the lower tibia, on in the olecranon and one in an iliac bone. The clinical course was greater than one year in three patients, and greater than one month in four others. The clinical presentation was a septic arthritis of the knee joint in three patients and of the hip in one, with rupture of the abscess into the soft tissues in three cases and a central intra-osseous collection in four. Biological features of infection were present in all patients. Imaging (x-ray, CT) showed a bone defect in the metaphyseal or metaphyseal epiphyseal region in all cases with condensed contours and a fistulous tract to a joint or soft tissue. Surgical treatment was proposed in all cases to treat the causal lesion by saucerisation and drainage of the intra-osseous abscess. The defect was filled with an autologous graft in one case and by cement in another. The germ identified in 70% of the cases was a Staphylococcus aureus. Adapted antibiotics were delivered for eight weeks on average. Results: One patient had a secondary fistula which developed early after excision of a central abscess of the proximal tibia; dry drainage was achieved after cover with a medial gastrocnemian flap. At mean 27 months follow-up, all lesions have cured without recurrence; blood tests returned to normal. Radiographically, the defect exhibited bone remodelling visible in the absence of surgical filling. Regarding function, there was one stiff knee due to adherence on the extensor system. Discussion: The Brodie abscess is a form of chronic osteomyelitis. It is a rare condition generally observed in young subjects since the majority of reported cases have occurred during the second decade of life. Clinically, the Brodie abscess can be “cold” with little or no overt expression, or more readily “hot” with a syndrome of acute infection and fistulisation to soft tissue. Fistulisation to a joint can mislead the diagnosis to septic arthritis as occurred in one of our patients who underwent two revisions for septic recurrent arthritis of the knee. Most Brodie abscesses are located in the metaphysic. A double metaphyseal and epiphyseal localisation through the growth plate is rare, resulting from an old septic process with inevitable joint collection as in one of our patients aged ten years. Discovery of a second concomitant localisation can be explained by an insufficient or inadequate treatment of the initial focus as we also observed in one case. The classical radiographic image of a Brodie abscess is observed in only two-thirds of the cases. Computed tomography is highly contributive demonstrating possible infra-radiographic fistulisation to a joint or soft tissue as occurred in most of our patients. The Brodie abscess can also simulate bone tuberculosis, hydatic cyst, or bone tumour. Surgically, we adopted to therapeutic strategies: excision of the
Introduction. In orthopaedics one of the most common complications is infection. The occurrence of a postoperative infection significantly increases the failure rate; both in the case of prosthetic and trauma surgery. Some patients despite a meticulous antiseptic procedures, a close monitoring of controls peri- and post-operative undergo the development of infection of the fixation devices with the risk of developing osteomyelitis. This risk is highly increased in the distal leg because of the known problems with blood supply and poor muscle coverage. The functionality of the affected segment is impaired, quoad fuctionem, with increased risk of amputation and sometimes with poor prognosis, quoad vitam. The therapeutic strategy proposed by our group is to treat an osteomyelitic site as a pseudo-tumor with a megaimplant following a ladder strategy driven by the NUSS classification. This work shows our experience with a developing system by Waldemar-LINK highlighting critical issues and preliminary results. Objectives. The purpose of this study is to evaluate retrospectively the early outcome after the implantation of this megaprosthesis of the lower leg in
Many authors have reported a shorter treatment time when using trifocal bone transport (TFT) rather than bifocal bone transport (BFT) in the management of long segmental tibial bone defects. However, the difference in the incidence of additional procedures, the true complications, and the final results have not been investigated. A total of 86 consecutive patients with a long tibial bone defect (≥ 8 cm), who were treated between January 2008 and January 2015, were retrospectively reviewed. A total of 45 were treated by BFT and 41 by TFT. The median age of the 45 patients in the BFT group was 43 years (interquartile range (IQR) 23 to 54).Aims
Patients and Methods
Humerus non-unions are difficult to treat, especially those with infected non-unions, bone loss, deformity, previous multiple surgeries and/or broken hardware. This paper presents our experience with the use of the Ilizarov frame with humerus non- unions. Eight consecutive humerus non-unions were treated using the Ilizarov frame. Only loose or infected hardware was removed. The Ilizarov frame was applied using safe zones principles of Ilizarov, Catagni and Paley. Aspetic non-unions were treated with deformity correction, sequential compression and distraction, bone grafting and intramedullary stabilisation for diaphyseal nonunions. Infected diaphyseal non-unions were treated intra-medullary reaming with or without excision of
In the present study, we aimed to assess whether gelatin/β-tricalcium phosphate (β-TCP) composite porous scaffolds could be used as a local controlled release system for vancomycin. We also investigated the efficiency of the scaffolds in eliminating infections and repairing osteomyelitis defects in rabbits. The gelatin scaffolds containing differing amounts of of β-TCP (0%, 10%, 30% and 50%) were prepared for controlled release of vancomycin and were labelled G-TCP0, G-TCP1, G-TCP3 and G-TCP5, respectively. The Kirby-Bauer method was used to examine the release profile. Chronic osteomyelitis models of rabbits were established. After thorough debridement, the osteomyelitis defects were implanted with the scaffolds. Radiographs and histological examinations were carried out to investigate the efficiency of eliminating infections and repairing bone defects.Objective
Methods
Extracorporeal Irradiation and Reimplantation (EIR) of tumor bearing bone segments is an alternative reconstruction method for major osseous resections. In contrast with endoprosthetic reconstruction, EIR is a biologic solution and after a prolonged healing and remodeling period it is expected to create a structural and metabolic almost normal bone. After oncologic resection the bone segment is cleaned from adhered soft tissues and send to irradiation which kills malignant and normal cells. Reimplantation consists of fixation, mostly by plates, vascularised fibular graft insertion in the medullary canal, iliac bone graft in critical sites and ligamentous sutures. Since 2001 fifteen patients were submitted to EIR in our institution. Resections affected seven distal femurs, four proximal tibias, one acetabulum, one iliac bone and the proximal forehand bones once which bear 11 osteosarcomas, 2 Ewing’s sarcomas, 1 chondrosarcoma and 1 rhabdomyosarcoma. There were six males and nine females with age ranging from five to 55 years. Ten patients were submitted to osteoarticular reconstructions, three to intercalary and two to partial pelvis reconstructions. Local recurrence leading to amputation occurred in one patient and resection of an
Purpose of study: Long bone chronic osteomyelitis may result in limb length discrepancy by shortening of the affected bone when the physis is damaged. Little is known about the rates of overgrowth of
This study describes the use of the Masquelet technique to treat
segmental tibial bone loss in 12 patients. This retrospective case series reviewed 12 patients treated between
2010 and 2015 to determine their clinical outcome. Patients were
mostly male with a mean age of 36 years (16 to 62). The outcomes
recorded included union, infection and amputation. The mean follow-up
was 675 days (403 to 952). Aims
Patients and Methods
Calcium sulphate (CaSO4) is a resorbable material
that can be used simultaneously as filler of a dead space and as
a carrier for the local application of antibiotics. Our aim was
to describe the systemic exposure and the wound fluid concentrations
of vancomycin in patients treated with vancomycin-loaded CaSO4 as
an adjunct to the routine therapy of bone and joint infections. A total of 680 post-operative blood and 233 wound fluid samples
were available for analysis from 94 implantations performed in 87
patients for various infective indications. Up to 6 g of vancomycin
were used. Non-compartmental pharmacokinetic analysis was performed
on the data from 37 patients treated for an infection of the hip.Aims
Patients and Methods
We have observed clinical cases where bone is formed in the overlaying muscle covering surgically created bone defects treated with a hydroxyapatite/calcium sulphate biomaterial. Our objective was to investigate the osteoinductive potential of the biomaterial and to determine if growth factors secreted from local bone cells induce osteoblastic differentiation of muscle cells. We seeded mouse skeletal muscle cells C2C12 on the hydroxyapatite/calcium sulphate biomaterial and the phenotype of the cells was analysed. To mimic surgical conditions with leakage of extra cellular matrix (ECM) proteins and growth factors, we cultured rat bone cells ROS 17/2.8 in a bioreactor and harvested the secreted proteins. The secretome was added to rat muscle cells L6. The phenotype of the muscle cells after treatment with the media was assessed using immunostaining and light microscopy.Objectives
Materials and Methods
A clinical investigation into a new bone void filler is giving
first data on systemic and local exposure to the anti-infective
substance after implantation. A total of 20 patients with post-traumatic/post-operative bone
infections were enrolled in this open-label, prospective study.
After radical surgical debridement, the bone cavity was filled with
this material. The 21-day hospitalisation phase included determination
of gentamicin concentrations in plasma, urine and wound exudate, assessment
of wound healing, infection parameters, implant resorption, laboratory
parameters, and adverse event monitoring. The follow-up period was
six months. Objective
Method
The aim of this study was to identify risk factors for the failure
of exchange nailing in nonunion of tibial diaphyseal fractures. A cohort of 102 tibial diaphyseal nonunions in 101 patients with
a mean age of 36.9 years (15 to 74) were treated between January
1992 and December 2012 by exchange nailing. Of which 33 (32%) were
initially open injuries. The median time from primary fixation to
exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to
9.8 months). The main outcome measures were union, number of secondary fixation
procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify
risk factors for failure to achieve union. Aims
Patients and Methods
The treatment of chronic osteomyelitis often
includes surgical debridement and filling the resultant void with antibiotic-loaded
polymethylmethacrylate cement, bone grafts or bone substitutes.
Recently, the use of bioactive glass to treat bone defects in infections
has been reported in a limited series of patients. However, no direct comparison
between this biomaterial and antibiotic-loaded bone substitute has
been performed. In this retrospective study, we compared the safety and efficacy
of surgical debridement and local application of the bioactive glass
S53P4 in a series of 27 patients affected by chronic osteomyelitis
of the long bones (Group A) with two other series, treated respectively
with an antibiotic-loaded hydroxyapatite and calcium sulphate compound
(Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded
demineralised bone matrix (Group C; n = 22). Systemic antibiotics
were also used in all groups. After comparable periods of follow-up, the control of infection
was similar in the three groups. In particular, 25 out of 27 (92.6%)
patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out
of 22 (86.3%) in Group C showed no infection recurrence at means
of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up,
respectively, while Group A showed a reduced wound complication
rate. Our results show that patients treated with a bioactive glass
without local antibiotics achieved similar eradication of infection
and less drainage than those treated with two different antibiotic-loaded
calcium-based bone substitutes. Cite this article:
Limited forefoot amputation in diabetic patients
with osteomyelitis is frequently required. We retrospectively reviewed
diabetic patients with osteomyelitis, an unhealed ulcer and blood
pressure in the toe of >
45 mmHg who underwent limited amputation
of the foot with primary wound closure. Between 2006 and 2012, 74
consecutive patients with a mean age of 67 years (29 to 93), and
a median follow-up of 31 months, were included. All the wounds healed
primarily at a median of 37 days (13 to 210; mean 48). At a median
of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered
a further ulceration. Of these, 12 patients (16% of the total) required
a further amputation. We conclude that primary wound closure following limited amputation
of the foot in patients with diabetes is a safe and effective technique
when associated with appropriate antibiotic treatment. Cite this article:
We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site. Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients.
A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.
Osteomyelitis is one of the oldest diseases known. It took many years before the acute infection could be brought under control with antibiotics and chronic osteomyelitis remains difficult to manage. The modern history of the disease is reflected in the pages of the
Based on the first implementation of mixing antibiotics
into bone cement in the 1970s, the Endo-Klinik has used one stage
exchange for prosthetic joint infection (PJI) in over 85% of cases.
Looking carefully at current literature and guidelines for PJI treatment,
there is no clear evidence that a two stage procedure has a higher
success rate than a one-stage approach. A cemented one-stage exchange
potentially offers certain advantages, mainly based on the need
for only one operative procedure, reduced antibiotics and hospitalisation time.
In order to fulfill a one-stage approach, there are obligatory pre-,
peri- and post-operative details that need to be meticulously respected,
and are described in detail. Essential pre-operative diagnostic
testing is based on the joint aspiration with an exact identification
of any bacteria. The presence of a positive bacterial culture and
respective antibiogram are essential, to specify the antibiotics
to be loaded to the bone cement, which allows a high local antibiotic
elution directly at the surgical side. A specific antibiotic treatment
plan is generated by a microbiologist. The surgical success relies
on the complete removal of all pre-existing hardware, including
cement and restrictors and an aggressive and complete debridement
of any infected soft tissues and bone material. Post-operative systemic
antibiotic administration is usually completed after only ten to
14 days. Cite this article:
Ciprofloxacin hydrochloride-loaded microspheres were prepared by a spray-drying method using pectin and chitosan. The effects of different polymers and drug ratios were investigated. The most appropriate carriers were selected by The drug was released rapidly from the pectin carrier but this was more sustained in the chitosan formulation. Chitosan microspheres loaded with ciprofloxacin hydrochloride were more effective for the treatment of osteomyelitis than equivalent intramuscular antibiotics.
We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistant pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.
We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.
We identified 1305 femoral impaction bone grafting revisions using the Exeter stem performed between 1989 and 2002 in 30 hospitals throughout Sweden. There were 1188 patients with a mean age of 71 years (29 to 94) followed up for between five and 18 years. The participating departments reported 70 further revisions in total, of which 57 could also be identified on the Swedish National Arthroplasty Registry. Kaplan-Meier survivorship for all causes of failure was 94.0% (95% confidence interval (CI) 92 to 96) for women and 94.7% (95% CI, 92 to 96) for men at 15 years. Survivorship at 15 years for aseptic loosening was 99.1% (95% CI 98.4 to 99.5), for infection 98.6% (95% CI 97.6 to 99.2), for subsidence 99.0% (95% CI 98.2 to 99.4) and for fracture 98.7% (95% CI 97.9 to 99.2) Statistically significant predictors of failure were the year in which revision was conducted (p <
0.001). The number of previous revisions was slightly above the level of signifance (p = 0.056). Age, gender, the length of the stem and previous septic loosening were not predictors of failure (p = 0.213, p = 0.399, p = 0.337, p = 0.687, respectively). The difference in survivorship between high- and low-volume departments was only 3% at ten years. We conclude that impaction bone grafting with the Exeter stem has an excellent long-term survivorship following revision arthroplasty. The technique of impaction grafting appears to be reliable, can be learned rapidly and produces a predictably low incidence of aseptic loosening.
Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts. Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.
We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.
The management of chronic osteomyelitis requires the excision of necrotic and infected material followed by the prolonged administration of antibiotics. Sequestrectomy may be required before an involucrum has formed, resulting in a longitudinal bone defect. This can be difficult to fill. Vascularised grafts are complicated by a high rate of recurrent infection and thrombosis. We have managed defects of long bones in children after sequestrectomy by the use of non-vascularised fibular grafts harvested subperiosteally and held by an intramedullary Kirschner wire. Eight children underwent this procedure. In six the tibia was involved and in one each the humerus and radius. One patient was lost to follow-up. Six grafts united at both ends within 12 weeks. The seventh developed an infected nonunion distally which united after further debridement. One patient required a further sequestrectomy which did not compromise union. We have found this to be a straightforward technique with reliable results and were able to salvage the limb in all the seven patients who were reviewed.
In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient. We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.
Implantation of allograft bone is an integral part of revision surgery of the hip. One major concern with its use is the risk of transmission of infective agents. There are a number of methods of processing allograft bone in order to reduce this risk. One method requires washing the tissue using pulsed irrigation immediately before implantation. We report the incidence of deep bacterial infection in 138 patients (144 revision hip arthroplasties) who had undergone implantation of allograft bone. The bone used was fresh-frozen, non-irradiated and pulse-washed with normal saline before implantation. The deep infection rate at a minimum follow-up of one year was 0.7%. This method of processing appears to be associated with a very low risk of allograft-related bacterial infection.