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BACKGROUND: Despite the availability of multiple treatment options, management of tibial bone loss continues to be a challenge. Free vascularized fibula graft (FVFG) with a skin paddle offers better advantages over the other methods. We aimed to study the functional outcomes and QALY of patients with large tibial bone defects following FVFG with a locking plate. MATERIALS AND METHODS: We analyzed 26 consecutive patients with large tibial bone defects treated by free vascularized fibular graft (FVFG) and stabilization using a long locking plate between 2009 and 2018. All were followed up for a mean period of 42 months (24 to 120 months). Bony union, graft hypertrophy, and complications such as stress fracture and infections were assessed. Multivariate regression analysis was performed to identify any association between demographic factors, injury characteristics, treatment-related factors, and fibular hypertrophy. Additionally, The EQ-5D quality-of-life (QOL) indices were obtained using the SF-12 score to evaluate the patients' overall quality of life. RESULTS: The mean age of the patients at the time of presentation was 36.26 yrs (range, 18-60 years). The cause of bone loss was open injury in 16 patients and infected nonunion in 10 patients. Complete union was achieved in 25 patients (96 %) without any requirement of additional surgical procedures. The mean union time of the graft was 4.04 months (range, 3-6 months). The mean fibular hypertrophy calculated by De Boer index was 0.61 %, 11 %, 28.24 % and 52.52 % at 3,6 months and 1 and 2 years respectively. Patients with metaphyseal bone loss have significant fibular hypertrophy. Participants in our study experienced a quality of life equivalent to 0.88 (range 0.79-0.99) of perfect health. CONCLUSIONS: FVFG with skin paddle and LCP fixation for massive tibial bone loss achieved satisfactory outcome and QALY even in the challenging healthcare environment of South India, a developing country.It maintains alignment, promotes graft hypertrophy, and prevents stress fractures. LEVEL OF EVIDENCE: Level 4 LEVEL OF CLINICAL CARE: Level I Tertiary trauma centre.

Asunto(s)

Placas Óseas , Trasplante Óseo , Peroné , Fijación Interna de Fracturas , Curación de Fractura , Calidad de Vida , Fracturas de la Tibia , Humanos , Masculino , Peroné/trasplante , Peroné/irrigación sanguínea , Femenino , Adulto , Persona de Mediana Edad , Fracturas de la Tibia/cirugía , Fijación Interna de Fracturas/métodos , Trasplante Óseo/métodos , Resultado del Tratamiento , Adolescente , Adulto Joven , Curación de Fractura/fisiología , Estudios Retrospectivos , Tibia/cirugía , Colgajos Tisulares Libres/irrigación sanguínea

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Background: Ilizarov external fixation has become the treatment of choice for infected non-union of tibia. Varying degrees of bone loss and different strategies of treatment in the published reports make comparing outcomes difficult. This study hopes to bridge this gap in the literature by focussing exclusively on bone transport in patients with bone loss of 5 cm or more. Methodology: This is a prospective case series conducted at a tertiary level orthopaedic speciality hospital. Outcomes are measured by Association of the Study and Application of Method of Ilizarov (ASAMI) bony scores, ASAMI functional scores, Lengthening Index and by assessing complications encountered. Results: There were 49 patients in this study with an average of 9.57 cm bone gap. Among these, 29 patients had a bone gap of 5-10 cm and 20 patients had a bone gap of ≥ 11 cm. According to the ASAMI bony score, 42 patients had excellent or good outcomes with two fair results and five poor results. The ASAMI functional scores were 45 excellent to good outcomes, four fair and no poor results or failures. Fixed flexion deformity of the knee of more than 5°, ankle stiffness and soft tissue interposition were significantly more frequent in those with bone gap of ≥ 11 cm. Trifocal transport and bone grafting at docking significantly improved the lengthening index. Conclusion: Even massive bone defects of 11 cm or more can be reliably healed by bone transport using Ilizarov external fixation, but with a significantly higher rate of complications. Level of evidence: Level IV.

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INTRODUCTION: The GeneXpert® MRSA/SA SSTI (Methicillin Resistant Staphylococcus aureus/S. aureus skin and soft tissue infection) PCR test allows early detection of methicillin resistance in staphylococci. This test was developed for skin infections and has been evaluated for prosthetic joint infections but, to our knowledge, has not been evaluated for hardware infections outside of arthroplasties. Furthermore, we conducted a retrospective study in patients with non-prosthetic osteosynthesis hardware aiming: (1) to identify the diagnostic values of the PCR test compared to conventional cultures and the resulting rate of appropriate antibiotic therapy; (2) to identify the rate of false negative (FN) results; (3) to identify and compare the rates of failure of infectious treatment (FN versus others); (4) to search for risk factors for FN of the PCR test. HYPOTHESIS: The PCR test allowed early and appropriate targeting of antibiotic therapy. MATERIAL AND METHODS: The results of PCR tests and conventional cultures for osteoarticular infections of non-prosthetic hardware over four years (2012-2016) were compared to identify the diagnostic values of using the results of conventional culture as a reference and the rate of appropriate antibiotic therapies. Infectious management failures between the results of the FN group and the others were compared, and variables associated with a FN of the PCR test were identified. RESULTS: The analysis of 419 PCR tests allowed us to establish a sensitivity of 42.86%, a specificity of 96.82%, a positive predictive value of 60% and a negative predictive value of 93.83%. Using the results of the PCR test for the targeting of postoperative antibiotic therapy, it was suitable for staphylococcal coverage in 90.94% (381/419). The rates of patients for whom infectious treatment failed were not significantly different between the FN group and the other patients (20.8% versus 17.7%, respectively; Hazard Ratio=1.12 (95%CI 0.47-2.69, p=0.79)). A skin opening during the initial trauma (p=0.005) and a polymicrobial infection were significantly associated with a risk of FN from the PCR test (p<0.001). CONCLUSION: The PCR test makes it possible to reduce the duration of empirical broad-spectrum antibiotic therapy during the treatment of an infection of osteosynthesis hardware but causes a lack of antibiotic coverage in 9.06% of cases. LEVEL OF EVIDENCE: III; diagnostic case control study.

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Antibiotic impregnated cement coated intramedullary nails (ACCINs) have been used in clinical practice for many years and have been shown to help eradicate infection in tibial osteomyelitis while providing stability. We present a novel technique for preparation using bronchoscopy tubing, as well as technical tips and a review of the literature, for ease of preparation and potential subsequent retrieval.

Asunto(s)

Fijación Intramedular de Fracturas , Osteomielitis , Fracturas de la Tibia , Humanos , Antibacterianos , Broncoscopía , Fracturas de la Tibia/cirugía , Clavos Ortopédicos , Osteomielitis/cirugía , Fijación Intramedular de Fracturas/métodos , Cementos para Huesos

RESUMEN

Purpose: The purpose of this study was to comparatively evaluate cement debonding at the time of removal of antibiotic cemented coated nails (ABNs) with cores made with a guidewire ($120), a regular intramedullary nail ($1100) or a threaded rod from a circular frame external fixator set ($60). Methods: A retrospective study was performed on 32 ABNs that had been implanted for long bone infections after intramedullary nailing. All ABNs were manufactured intraoperatively by the treating surgeon using 2 grams of vancomycin and single package of Tobramycin Simplex Cement (Stryker, Kalamazoo, MI). The powder, antibiotics, and polymer were mixed and then injected into an ABN cement mold (Bonesetter Holdings USA). Debonding was assessed at time of removal by the operating surgeon. Rates of cement debonding between the 3 groups were statistically compared. Results: Debonding occurred in 0/12 of the cement nails manufactured with an intramedullary nail, 0/7 threaded rod ABNs, and 6/13 guidewire ABNs. There was a significant difference in the rate of debonding between the 3 groups (P < 0.01). Removal of the remnant cement was accomplished with thin osteotomes, long pituitary rongeurs, or reamers. The canal was visualized using an arthroscope to ensure complete removal of the cement. Conclusion: ABNs fabricated with standard intramedullary nails or threaded rods did not lead to any debonding. Debonding of the cement from the inner core of an antibiotic nail often requires significant effort to remove the remnant cement. Given that threaded rods are often cheaper than guidewires, we recommend that ABNs be fabricated with either threaded rods or interlocking nails, but not guidewires, depending on the level of stability required.

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Here, we describe the case of an 80-year-old female patient with type II insulin-dependent diabetes mellitus with a left proximal tibia fracture. Open reduction internal fixation was performed using a locking plate. After the surgical site infection, the plate was removed and negative-pressure wound therapy was applied. The bone was covered with a vastus medialis muscle flap, and a split-thickness skin graft and external fixation using an Ilizarov device was performed as the definitive treatment.

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INTRODUCTION: The objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails. METHODS: We retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients' distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates. RESULTS: We included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036). CONCLUSION: Antibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement. LEVEL OF EVIDENCE: III comparative, observational, non-randomized.

Asunto(s)

Antibacterianos , Enfermedades Óseas Infecciosas , Clavos Ortopédicos , Fracturas del Fémur , Fracturas no Consolidadas , Fracturas de la Tibia , Humanos , Antibacterianos/administración & dosificación , Cementos para Huesos , Fémur/lesiones , Fémur/cirugía , Fijación Intramedular de Fracturas/instrumentación , Fijación Intramedular de Fracturas/métodos , Gentamicinas/administración & dosificación , Reoperación , Estudios Retrospectivos , Tibia/lesiones , Tibia/cirugía , Fracturas de la Tibia/complicaciones , Fracturas de la Tibia/tratamiento farmacológico , Fracturas de la Tibia/cirugía , Resultado del Tratamiento , Vancomicina/administración & dosificación , Fracturas no Consolidadas/tratamiento farmacológico , Fracturas no Consolidadas/etiología , Fracturas no Consolidadas/cirugía , Materiales Biocompatibles Revestidos , Fracturas del Fémur/complicaciones , Fracturas del Fémur/tratamiento farmacológico , Fracturas del Fémur/cirugía , Enfermedades Óseas Infecciosas/tratamiento farmacológico , Enfermedades Óseas Infecciosas/etiología

RESUMEN

The reconstruction of segmental bone defects after surgical treatment of infected delayed unions as well as nonunions, places the highest demands on the surgical technical implementation. After treating the fracture-related infection, guaranteeing biomechanical stability is crucial for the success of the treatment. The presented case describes the successful treatment of an infected delayed union after an open metadiaphyseal comminuted fracture of the proximal femur using a modified Masquelet technique. A solid allogeneic bone graft in combination with autologous cancellous bone were inserted into a 7 cm subtrochanteric defect zone and stabilized with a combined plate and nail osteosynthesis.

Asunto(s)

Fracturas Conminutas , Fracturas Abiertas , Humanos , Fracturas Conminutas/cirugía , Curación de Fractura , Fracturas Abiertas/cirugía , Fémur , Extremidad Inferior

RESUMEN

INTRODUCTION: Consensus is lacking regarding management of posttraumatic infected diaphyseal nonunions of femur following intramedullary nailing. Present study reports outcomes of single stage standardised treatment protocol using monolateral rail external fixator/limb reconstruction system in this type of infected diaphyseal femoral nonunions. METHODS: This retrospective study included 26 patients with mean age of 31.7 years having posttraumatic infected diaphyseal femoral nonunions following intramedullary nailing and managed with radical debridement and monolateral rail fixator. The results were assessed by Association for the Study and Application of the Method of Ilizarov criteria. RESULTS: Mean intraoperative bone gap was 4.34 (range, 2-7) cm. Mean gain in bone length was 4.04 (range, 0-7) cm. Fracture united primarily in 22 cases and after freshening of edges, fixator adjustment and fibular grafting in three more patients. Infection persisted in one patient. Most common complications were superficial pin tract infection (15 patients) and loss of more than 30° knee flexion (13 patients). The bone results were excellent, good, and poor in 15, 9, and 2 patients, respectively. The functional results were excellent, good, fair, and poor in 11,13,1 and 1 patient, respectively. CONCLUSION: Single stage procedure including radical debridement, acute docking, distraction osteogenesis at corticotomy site and stabilization with monolateral rail fixator reliably achieves good to excellent bone and functional results, union and eradication of infection in majority of infected nonunions of femoral diaphysis developing after intramedullary fixation. We recommend acute docking in bone gap ≤ 5 cm.

Asunto(s)

Fracturas del Fémur , Fijación Intramedular de Fracturas , Fracturas no Consolidadas , Osteogénesis por Distracción , Humanos , Adulto , Estudios Retrospectivos , Diáfisis , Fémur/cirugía , Osteogénesis por Distracción/métodos , Fijadores Externos , Fracturas del Fémur/cirugía , Fracturas no Consolidadas/etiología , Fijación Intramedular de Fracturas/efectos adversos , Resultado del Tratamiento

RESUMEN

Aim: To highlight the role of the Masquelet technique as a limb salvage procedure for a neuropathic patient presenting with infected non-union of proximal tibia. Background: The management of an infected non-union in neuropathic patients is most challenging; with various treatment options available, the prognosis is often guarded. Case description: A 37-year-old male with chronic polyneuropathy, also possessing a contralateral midfoot Charcot arthropathy secondary to a history of alcohol abuse, developed infection after a proximal tibial osteotomy for a preceding mal-non-union of a proximal tibia fracture. The management included hardware removal, excision of necrotic bone, interim insertion of antibiotic-loaded bone cement followed by an acute shortening and revision of the internal fixation utilising a second surgical incision. Successful bone union and eradication of infection was achieved and maintained after 13 months follow-up. Conclusion: A successful outcome was achieved for an infected non-union of a long bone in a neuropathic patient using the Masquelet technique which was then followed with a second-stage removal of the spacer and shortening. By performing the revision ORIF surgery utilising a different skin incision in the setting of complicated previous surgical scars proved to be a viable technique towards reducing risk of recurrence of infection and a good outcome. Clinical significance: Utilisation of the Masquelet technique and limb shortening in a staged manner for the management of long bone infections in neuropathic patients has not been reported before and may be valuable in such demanding clinical situations. How to cite this article: Mahmoud AN, Watson JT, Horwitz DS. Modified Masquelet Technique and Primary Tibial Metaphyseal Shortening for the Management of Proximal Tibial-infected Non-union in a Patient with Alcohol-induced Neuropathy: A Case Study. Strategies Trauma Limb Reconstr 2023;18(3):181-185.

RESUMEN

BACKGROUND: Accurate preoperative diagnosis of infected nonunion remains a challenge. Here, we evaluated the diagnostic potential of novel biomarkers for infected nonunion. METHODS: A cohort of 275 patients who underwent surgery for suspected septic nonunion after open reduction and internal fixation were enrolled. Preoperatively analyzed clinical parameters included white blood cell (WBC) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin, globulin, albumin-to-globulin ratio (AGR), plasma D-dimer, plasma fibrinogen, platelet count (PC), monocyte-lymphocyte ratio (MLR), neutrophil-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR). Receiver operating characteristic (ROC) curves, sensitivity, and specificity were utilized to compare the diagnostic potential of those biomarkers. RESULTS: The WBC count and levels of CRP, ESR, NLR, MLR, PLR, PC, plasma D-dimer, plasma fibrinogen, and globulin in infected nonunion patients were significantly higher (p < 0.05) than those in aseptic patients. The albumin and AGR levels of the infected nonunion group were significantly lower (p < 0.05) than the aseptic group. The ROC curve analysis showed that the diagnostic accuracy of AGR and plasma fibrinogen was good. The combination of AGR with plasma fibrinogen had the highest area under the curve (AUC) (0.916). The sensitivity and specificity were 70.27% and 91.04% for AGR, and 67.57% and 84.08% for plasma fibrinogen, respectively. The combination of AGR with plasma fibrinogen showed a sensitivity of 86.49% and specificity of 92.54%. In patients with comorbidities, the diagnostic accuracy of the combination of AGR with plasma fibrinogen was also good. CONCLUSIONS: AGR and plasma fibrinogen are promising biomarkers to improve the diagnosis of infected nonunion. The combination of AGR with plasma fibrinogen is a sensitive tool for screening infected nonunion.

Asunto(s)

Proteína C-Reactiva , Fibrinógeno , Humanos , Estudios Retrospectivos , Fibrinógeno/metabolismo , Reoperación , Proteína C-Reactiva/metabolismo , Biomarcadores , Albúminas

RESUMEN

AIMS: Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. METHODS: A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). RESULTS: At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of nonunion before surgery (1/10 with nonunion (10%) vs 5/90 without nonunion (5.6%); p = 0.570). Organisms with intermediate or high-grade resistance to gentamicin were significantly more likely in polymicrobial infections (9/21; 42.8%) compared with monobacterial osteomyelitis (7/79 (8.9%); p < 0.001). However, recurrence was not significantly more frequent when a resistant organism was present (1/16 for resistant cases (6.25%) vs 5/84 in those with a microbiologically sensitive infection (5.95%); p = 0.958). CONCLUSION: We found that a single-stage protocol, including the use of a high-delivery local antibiotic ceramic carrier, was effective over a period of several years. The method can be used in a wide range of patients, including those with significant comorbidities and an infected nonunion.Cite this article: Bone Joint J 2022;104-B(9):1095-1100.

Asunto(s)

Gentamicinas , Osteomielitis , Implantes Absorbibles , Antibacterianos/uso terapéutico , Cerámica , Desbridamiento/métodos , Humanos , Osteomielitis/diagnóstico , Osteomielitis/tratamiento farmacológico , Osteomielitis/cirugía , Resultado del Tratamiento

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PURPOSE: Orthopaedic-related wounds are critical situations calling for care to avoid deep infections and its consequences. The purpose of this study was to evaluate the efficacy of using honey for care of orthopaedic-related wounds with limited resources. PATIENTS AND METHODS: This prospective study included 50 cases with an average age of 38.18 (range 17-63) years with 38 males and 12 females. The most frequent wound location was the leg (41 patients; 82%), then the foot (six patients; 12%), and the ankle in three patients (6%). The aetiologies were open fractures (34 cases; 68%), infected tibial non-unions (nine cases; 18%), and post-operative infections (seven cases; 14%). Exposed tendon was present in three cases. Bone exposure was present in two cases. Deep infection was present in 29 cases (58%). Besides treating the primary cause, a ribbon of gauze soaked with honey was applied to the wounds after thorough saline washing. RESULTS: Wound sizes were variable. All cases showed improvement in all parameters with complete wound healing and full coverage of bone and tendons. Recurrence of deep infection occurred in three cases and treated by debridement. One case needed sequestrectomy of a small exposed tibial cortical fragment. Exposed tendon cases showed superficial necrosis which was treated by simple debridement. Initial mild itching occurred in five patients with spontaneous resolution. CONCLUSION: With treating the underlying aetiology and optimising the patient's general condition, honey was an effective, simple, and affordable method of wound care in different orthopaedic conditions even with exposed bone or tendons.

Asunto(s)

Fracturas Abiertas , Miel , Ortopedia , Adolescente , Adulto , Vendajes , Femenino , Fracturas Abiertas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto Joven

RESUMEN

Antibiotic cement-coated intramedullary nails (ACCINs) are increasing in popularity as a viable solution for the treatment of fracture-related infections (FRIs), infected long bone nonunions, and arthrodeses without an external fixator. ACCINs effectively manage to fulfill three of the basic principles for eradicating osteomyelitis: dead space management, antibiotic delivery, and bone stability. We performed a retrospective review of 111 patients who were treated with ACCINs between January 2014 and December 2020. In our series, 87.4% (n = 97) of patients achieved healed and uninfected bone or stable arthrodesis at a mean follow-up of 29.2 months (range, 6-93 months). Additionally, 69.1% (n = 67) of healed patients were resolved after only one procedure, and the remainder (30.9%, n = 30) healed after one or more additional procedures. The mean number of additional procedures was 2.1 (range, 1-6 additional procedures). The overall limb salvage rate was 93.7% (n = 104). The majority of the total cohort were successfully treated in only one surgery. This study suggests that ACCINs are effective in the treatment of FRIs, infected long bone nonunions, and infected ankle and knee arthrodeses.

RESUMEN

The treatment of infected non-unions of the femur and the tibia remains difficult and requires control of the infection and successful bone healing. Antimicrobial coating of intramedullary nails promises both infection control and stabilization for subsequent bone healing. Both results for custom-made and commercially available antimicrobial coating for intramedullary nails have been published in the past mainly consisting of retrospective case series. The purpose of this work is to review the published literature on techniques and clinical outcome of antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions. A systematic literature research in Medline, PubMed, Embase and Cochrane Library was performed in accordance to the PRISMA guidelines. Articles reporting on antimicrobial-coated intramedullary nails for the treatment of infected long bone non-unions were eligible for inclusion. In total, 22 publications were found reporting on 506 infected non-unions of the tibia and femur treated with an antimicrobial-coated nail. Most of them consisted of retrospective case series (72.7%). 469 and 37 patients were treated with an individual antibiotic-loaded PMMA-coating and commercially available gentamicin-coating for intramedullary nails, respectively. The overall infection eradication rate was 90.0% (range 68.7-100%) and the bone consolidation rate was 85.5% (range 57.9-100%). Coating specific side effects were not reported. In conclusion, the treatment of infected long bone non-unions with antimicrobial-coated nails is associated with a high infection control and bone consolidation rate and seems to be a reasonable treatment options with minimal side effects. However, scientific quality of the publications is low and randomized controlled trials are needed.

Asunto(s)

Clavos Ortopédicos , Fijación Intramedular de Fracturas , Antibacterianos/uso terapéutico , Fijación Intramedular de Fracturas/métodos , Curación de Fractura , Gentamicinas , Humanos , Polimetil Metacrilato , Estudios Retrospectivos , Resultado del Tratamiento

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BACKGROUND: The surgical treatment of osteitis or fracture-related infections (FRI) is often associated with large bone defects. The treatment of these defects remains a major challenge in trauma surgery. Within the concept of tissue engineering, the development of various hybrid bone graft substitutes, such as calcium hydroxyapatite with added antibiotics, is continuously progressing. OBJECTIVE: Chances and limitations in the treatment of osteitis with calcium hydroxyapatite containing antibiotics. MATERIAL AND METHODS: Overview of the results of a 2-stage (infection) pseudarthrosis model on rat femurs treated with Cerament® G (Bonesupport, Lund, Schweden). Evaluation of the clinical experiences based on three case examples of osteitis treated with calcium hydroxyapatite containing antibiotics (Cerament® G or Cerament® V). RESULTS: After establishment of a 2­stage pseudarthrosis model on the rat femur, the osteoconductive and osteoinductive potential of calcium hydroxyapatite containing antibiotics could be confirmed. In the clinical application, the use of Cerament® G seems to lead to a more favorable outcome in small cavitary defects. The recurrence rates are higher than previously described, especially for larger segmental defects. CONCLUSION: Taking the clinical and experimental results into consideration, a stricter evaluation of the indications for the use of Cerament® G is necessary to achieve the best possible outcome for patients.

Asunto(s)

Sustitutos de Huesos , Osteítis , Seudoartrosis , Sepsis , Animales , Antibacterianos/uso terapéutico , Sustitutos de Huesos/farmacología , Durapatita/uso terapéutico , Osteítis/tratamiento farmacológico , Seudoartrosis/tratamiento farmacológico , Ratas , Sepsis/tratamiento farmacológico

RESUMEN

INTRODUCTION: In the setting of periprosthetic total hip and knee arthroplasty (THA/TKA) infection, plating of the femur may be necessary for fracture fixation, prophylactic fixation of the femur, poor bone quality, or infected femoral shaft nonunion. The purpose of this study was to investigate infection control rates and fracture healing in patients receiving antibiotic cement coated plates in the setting of infected nonunion and periprosthetic infections. METHODS: We retrospectively reviewed a series of ten patients who had an antibiotic coated plate placed in the setting of periprosthetic infection or infected nonunion with a minimum follow-up of six months. 80 g of Simplex bone cement (Stryker, Mahwah, NJ) were mixed with 4 g of powdered vancomycin and 4.8 g of powdered tobramycin and applied to a dynamic compression plate with locking screw guides in every hole. The antibiotic loaded cement was allowed to harden before implantation. Outcome measures were designed to assess for fracture healing defined as three out of four cortices united on radiographs along with bearing full weight without pain and evidence of infection control defined as normalized erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the absence of antibiotic treatment with no clinical signs of infection. RESULTS: Ten patients were treated with an antibiotic cement coated plate in the settings of infectious nonunion and periprosthetic infection and followed for an average of three years (mean 21.4 months, seven months to 61 months). Eight patients (80%) went on to successful control of infection after initial procedure. Two patients developed chronic drainage and had a second antibiotic spacer with antibiotic cement coated plate placed before the infection was controlled. All patients obtained successful control of infection at latest follow-up showing no clinical signs of infection, normalized laboratory markers, and negative culture results. There were no reported mechanical failures of the implant, fractures of the femur, or soft tissue complications. CONCLUSION: An antibiotic cement coated plating technique is a viable option for periprosthetic THA and TKA infections requiring plating of the femur or in patients with an infected nonunion.

Asunto(s)

Fracturas del Fémur , Fracturas Periprotésicas , Antibacterianos/uso terapéutico , Cementos para Huesos/uso terapéutico , Placas Óseas/efectos adversos , Fracturas del Fémur/etiología , Fijación Interna de Fracturas/métodos , Humanos , Fracturas Periprotésicas/etiología , Fracturas Periprotésicas/cirugía , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

BACKGROUND: The diagnostic value of platelet indices has been evaluated in various infectious diseases but not in infected nonunion. The purpose of this study was to assess the usefulness of platelet indices for diagnosis of infected nonunion after open reduction and internal fixation. METHODS: This retrospective study was performed in patients who underwent primary fracture nonunion revision surgeries from January 2016 to December 2021. A total of 297 patients were included in the study: 96 with infected nonunion (group A) and 201 with aseptic nonunion (group B). Receiver operator characteristic (ROC) curve analysis was performed to evaluate diagnostic value of each index. Area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values were calculated and compared. RESULTS: Demographic characteristics were comparable between the two groups. White blood cell (WBC) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen, plasma D-dimer, platelet count (PC), plateletcrit, and ratio of platelet count to mean platelet volume (PC/MPV) were significantly higher, and MPV and platelet distribution width (PDW) significantly lower, in group A than in group B (P < 0.05). ROC analysis showed PC/MPV and plasma fibrinogen to have better diagnostic value than the other coagulation indicators (AUC of 0.801 and 0.807, respectively). The combination of ESR, plasma fibrinogen, and PC/MPV had good sensitivity and specificity for diagnosis of infected nonunion. PC/MPV had better diagnostic value than ESR and plasma fibrinogen in the subgroup of patients with coagulation-related comorbidities. CONCLUSIONS: Plasma fibrinogen and PC/MPV ratio might be useful parameters for early diagnosis of infected nonunion.

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Volúmen Plaquetario Medio , Área Bajo la Curva , Sedimentación Sanguínea , Humanos , Recuento de Plaquetas , Estudios Retrospectivos

RESUMEN

PURPOSE: Infected forearm nonunion remains a challenge for the hand surgeon. Autologous bone grafting within an induced membrane following implantation of a cement spacer, also known as the Masquelet technique, is a procedure used for addressing segmental bone defects. This report summarized our experience using this technique to treat the infected forearm nonunion. METHODS: We retrospectively reviewed a series of 32 patients treated for infected forearm nonunion by the 2-stage Masquelet technique between 2009 and 2018. There was an infected nonunion of the ulna in 28 patients and an infected nonunion of the radius in 4 patients. All patients had undergone an average of 2.7 procedures before presenting at our institution. Treatment involved a staged procedure in which an antibiotic-impregnated cement spacer was implanted into the bone defect following debridement without internal fixation. It was left in place for 4-6 weeks, during which time a membrane formed around the cement spacer. In the second stage, the induced membrane was incised, and the cement spacer was removed. The defect was then filled with cancellous autograft with the addition of internal fixation. Postoperative radiographs were taken for the evaluation of bone healing. The functional results of the affected forearm were evaluated for motion loss of elbow or wrist and rotation loss of forearm. RESULTS: All nonunions healed without recurrent infection or loosening of internal fixation at the time of final follow-up. All the patients showed substantial functional improvement, with excellent results in 14 patients, satisfactory results in 13, and unsatisfactory results in 5. CONCLUSIONS: The induced membrane technique is an effective solution for infected forearm nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Asunto(s)

Fracturas no Consolidadas , Fracturas del Cúbito , Trasplante Óseo/métodos , Antebrazo , Curación de Fractura , Fracturas no Consolidadas/cirugía , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Fracturas del Cúbito/cirugía

RESUMEN

Purpose: The rail fixator can improve the treatment outcome and provide good stability in patients with femoral bone transport. The purpose of this study is to investigate the clinical outcomes of bone transport using the Ilizarov technique by rail fixator in the treatment of femoral nonunion or bone defects caused by infection. Methods: Clinical feature and treatment outcomes of 32 consecutive adult patients with femoral nonunion or bone defect caused by infection from January 2012 to January 2019 at a minimum of 2 years of follow-ups were retrospectively analyzed. Data were collected on participants' demographic details. All difficulties related to bone transport were documented according to Paley's classification. The clinical outcomes were evaluated using ASAMI criteria at the last clinical visit. Results: All 32 patients with an average follow-up of 33.5 months. There were 17 problems, 21 obstacles, and 8 complications, and the complication rate per patient was 1.4. The main complications were pin-site infection (53.1%), axial deviation (21.9%), joint stiffness (18.8%), the delayed union of the docking site (18.8%), soft tissue incarceration(15.6%), delayed consolidation(6.3%), malunion(6.3%), and refracture (3.1%). All the patients achieved bone union, and no recurrence of infection was observed. The excellent and good rates of ASAMI bone and functional results were 87.5% and 81.3%, respectively. Conclusion: Bone transport using the Ilizarov technique is an effective method for the treatment of femoral nonunion or bone defect caused by infection, and rail fixators have obtained satisfactory results in terms of bone and functional results.