To determine if immediate closure of open wounds is safe, we examined our results over a five year period. Of the two hundred and ninety-seven open fractures, two hundred and fifty-five (86 %) were closed immediately. Grade III open fractures accounted for 24.2% of cases. The superficial infection rate was 10.9%. The combined deep infection and osteomyelitis rate was 4.7%. Neither region of injury, Gustilo grade, velocity of trauma, nor time to primary closure had a significant influence on the incidence of infection. Primary closure may be a safe practice and could be accepted as a viable treatment plan in the care of most open fractures. The purpose of this study was to determine if immediate primary closure of open fracture wounds is a safe practice without increased deep infections and delayed/ nonunions?. There was neither an increase in deep infection nor delayed union/non-union. Benefits include a decreased requirement for repeat debridements and soft tissue procedures, minimized surgical morbidity, hospital stay, and cost of treatment. Primary closure may be a safe practice in the care of most open fractures. The standard of care has been to leave traumatic wounds open after initial emergent surgical debridement. Due to orthopedic advancements and current resource limitations, treatment at our institution has evolved to immediate closure of all open wounds after adequate irrigation and debridement. Of the two hundred and ninety-seven open fractures, two hundred and fifty-five (86 %) were closed immediately after irrigation and debridement. Grades 3a, 3b and 3c open fractures accounted for 24.2% of cases. The superficial infection rate of primary closure was 10.9 %. All cases resolved with oral antibiotics. The combined deep infection and osteomyelitis rate was 4.7%. Neither region of injury, Gustilo grade, velocity of trauma, nor time to primary closure had a significant influence on the incidence of infection. The study reviewed all open fractures presenting to a Level One Trauma center over a five-year study period. Patients were followed until fracture union or complication resolution. Multiple variables were examined including patient demographics, injury mechanism, fracture location, Gustilo classification, time to antibiotic administration, surgical debridement and wound closure, and method of wound closure. Outcome measurement included infection or union problems

Objective. The development of surgical site infection in the early weeks following open reduction and internal fixation (ORIF) is a challenging problem. There are no evidence-based guidelines to direct the number of surgical debridements prior to definitive wound closure. The purpose of this study was to assess the success of infection resolution, and to identify risk factors for failure, in post-operative infections treated with a single debridement and primary wound closure. Methods. We retrospectively reviewed 61 postoperative infections (60 patients) that developed following fracture ORIF that were treated with a single debridement and primary closure. Data was collected from a review of the patients’ medical record. Variables were compared between the two groups using univariate and multivariate logistic regression analysis. Results. Twenty nine cases (48%) in 28 patients achieved successful outcome following a single debridement and primary closure without hardware removal. Risk factors for treatment failure, identified by multivariate analysis, were AO/OTA classification B and C type fractures (odds ratio = 2.539; 95% confidence interval = 1.110, 5.807; p = 0.027) and elevated C-reactive protein at admission (odds ratio = 1.017; 95% confidence interval = 1.002, 1.032; p = 0.026). Conclusions. Acute postoperative infection following ORIF treated by a single debridement and primary closure with hardware retention is successful in only half of the cases

To describe the success rate of surgical debridement and primary closure without implant removal in the treatment of postoperative spinal wound infections with instrumentation. One thousand four hundred fifty two posterior instrumented fusions were performed between 2000 and 2006. A retrospective record review identified 63 cases with acute (< 6 weeks) postoperative infection (4.6%). The preoperative diagnosis included fracture (24), adolescent idiopathic scoliosis (4), stenosis/degenerative spondylolisthesis (24), adult deformity (4), neuromuscular scoliosis (3), tumor (2), cervical myelopathy (2). All patients were treated with irrigation – debridement and closed suction drainage placement. Cultures were obtained, all wounds closed primarily and appropriate intravenous antibiotic treatments were initiated. The treatment protocol dictated the appropriate time to discontinue drains and antibiotics. The follow-up period ranged from 6 to 24 months. The majority of infections occurred during the early postoperative period (less than 2 weeks). Fifty-six (89%) resolved without recurrence with only one surgical debridement. Seven patients (11%) required a second operation for irrigation and debridement. Two patients (3%) required implant removal. Aggressive surgical treatment of postoperative spinal infections is essential for successful outcomes. Removal of implants is not necessary in acute infections. Delayed wound closure or second look operation could be avoided since primary closure offers accepted success rate

Introduction and Aims: Primary wound closure in open tibial fractures has not been recommended. Studies suggest that infections are not caused by the initial contamination but the organisms acquired in the hospital. Primary wound closure after adequate wound care and fracture stabilisation should be a safe concept. Method: We analysed 95 patients with open tibial fractures Gustilo-Anderson Type 1-3a treated with primary fracture stabilisation and delayed wound closure (group I) and primary fracture stabilisation and primary wound closure (group II). In group I, 46 patients (38 males, eight females) with a mean age of 30.2 years (range 16–56) were included. In group II, 49 patients (36 males, 13 females) with a mean age of 33.4 (range 18–69) were included. The mean follow-up in group I was 11.5 (range 9–18) and 11.7 (range 8–16) months. Results: The mean operating time in group I was 96 (range 45–180) minutes, in group II, 101 (range 40–170) minutes. The hospital stay in group I was 8.6 (range 3–20) days and in group II, 15.4 (range 4–52) days. One infectious case in group I was seen (2%) and two cases in group II (4.3%) were found. On further analysis, one case in group II, in our opinion, should not have been treated with primary fixation and wound closure. He only had three doses of a first generation cephalosporin and was operated 20 hours after admission to hospital. The corrected infection rate in group II should therefore should be calculated without that case and then is 2.1%. Conclusions: Our results support recent findings that primary wound closure after thorough debridement in Grade I and II open fractures does not increase the infection rate in comparison to the standard treatment. It shortens hospital stay and is cost-effective treatment. We conclude that primary wound closure is safe

Introduction. Primary wound closure in open tibial fractures has not been recommended. Traditionally initial debridement with fracture stabilisation and delayed wound closure was the accepted treatment. However this practice was developed before the use of prophylactic intravenous antibiotics and improved techniques for fracture stabilisation. Studies suggest that infections are not caused by the initial contamination but the organisms acquired in the hospital. Subsequent primary wound closure after adequate wound care and fracture stabilisation should be a safe concept and should not increase the rate of complications. Material/methods. In a retrospective study we analysed 95 patients with open tibial fractures Gustilo-Anderson Type 1-3a treated at two different teaching hospitals with primary fracture stabilisation and delayed wound closure as group I and primary fracture stabilisation and primary wound closure as group II. Exclusion criteria to the study were the following conditions: Grade 3b and 3c fractures, polytrauma, other fractures, significant medical history, previous surgery 6 months prior to admission. In group I 46 patients (38 males, 8 females) with a mean age of 30.2 years (16-56) were included. 19 sustained Grade 1 open, 16 Grade 2 open, 4 Grade 3a open and 7 gunshot fractures to the shaft of the tibia. In group II 49 patients (36 males, 13 females) with a mean age of 33.4 (18-69) were included. 19 sustained Grade 1 open, 19 Grade 2 open, 3 Grade 3a open and 8 gunshot fractures. The mean follow-up in group 1 was 11.5 (9-18) and 11.7 (8-16) months. The criteria for post-operative infection were clinical/radiological. Results. The mean operating time in group 1 was 96 (45-180) minutes, in group II 101 (40-170) minutes. The hospital stay in group 1 was 8.6 (3-20) days and in group 2 15.4 (4-52) days. One infectious case in group 1 was seen (2%) and two cases in group 2 (4.3%) were found. On further analysis one case in group 2 in our opinion should not have been treated with primary fixation and wound closure. He only had 3 doses of a first generation cephalosporin and was operated 20 hrs after admission to hospital. The corrected sepsis rate in group 2 should therefore should be calculated without that case and then is 2.1%. Discussion. Our results support recent findings that primary wound closure after thorough debridement in Grade 1+2 open fractures does not increase the infection rate in comparison to the standard treatment. It shortens hospital stay and is cost effective treatment. We conclude that primary wound closure is safe. Prospective multicentre studies are needed to further evaluate and result in change of the current practice

Purpose: Resection of pelvic sarcoma with limb preservation (internal hemipelvectomy) is a major undertaking. Resection requires large areas of soft-tissue to be removed. Because of wound complications, we manage these defects with immediate tissue transfer (ITT) at the time of resection when a large defect is anticipated. This study compares the outcomes of ITT with primary wound closure (PWC). Method: Twenty patients undergoing 22 separate procedures (1995–2007) were identified in our prospectively maintained database. Demographics, tumour type, operative data and complications, and functional scores (MSTS-1993, TESS) were collected. Results: Twelve defects were managed with ITT, nine with pedicled myocutaneous vertical rectus abdominis (VRAM) flaps (one received double VRAM flaps due to the large defect), two with tensor fascia lata (TFL) rotation flaps (one augmented by local V-Y advancement, the other with gluteus maximus rotation flap) and one received latissimus dorsi free tissue transfer. Four wound complications necessitated operative intervention in this group: two debrided VRAM flaps went on to heal and the two TFL flaps required revision: one to VRAM flap and the other to a latissimus dorsi free flap which ultimately suffered chronic infection and hindquarter amputation was performed. Ten defects were managed with PWC, and 5 wound complications occurred, all five suffered infection, one developed hematoma and one dehisced. One wound resolved with debridement, two healed after revision to pedicled gracilis and gluteus maximus myocutaneous flaps. Two patients were converted to hindquarter amputation due to chronic infection. Functional scores were collected on 8 of 12 living patients, at time of writing. The mean TESS scores were 83 and 73 in the ITT and PWC groups. Five patients in the ITT and 3 in the PWC group were deceased. Conclusion: Soft-tissue closure following pelvic sarcoma resection remains a difficult challenge, and our experience reflects that. There were fewer wound complications (33% v 50%) and slightly better function with ITT than PWC, but this was not statistically significant due to the small size of our study. Although small, this study suggests ITT should be considered whenever a large soft tissue defect is anticipated

Aims. Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results. In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing. Cite this article: Bone Jt Open 2024;5(3):236–242

Aims. To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures. Methods. We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication. Results. Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries. Conclusion. Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication. Cite this article: Bone Joint Open 2020;1-8:481–487

Purpose. Management of compound fractures, which have a higher infection risk than closed fractures, currently depends on surgeon training and past practice rather than evidence based practice. Some centres use delayed closure involving a second surgery with repeat debridement and wound closure 48 hours after initial debridement and fixation. Other centres use primary closure in the absence of gross contamination or major soft tissue deficits, where debridement, fixation and wound closure occur during the initial surgery. Delayed closure was used at our centre until January 2009 when the standard of care evolved to primary closure where appropriate. Primary closure allows more efficient OR utilization due to fewer OR visits, but it is unknown if primary closure increases the risk of infection, which can, in turn, lead to fracture non-union. The purpose of this pilot study was to complete a safety analysis of infection rates in the first 40 patients undergoing primary closure of a compound fracture; enrolment is ongoing and updated results will be presented. Method. Patients admitted in 2010 with a long bone(femur, tibia/fibula, humerus, radius/ulna) Gustilo grade I-IIIA compound fracture, without the following: gross organic contamination, compartment or crush syndrome, amputation, or gunshot wound, were eligible for primary closure at fracture fixation, and thus for study inclusion. The analysis compared primary closure subjects with matched delayed closure subjects taken from a previous prospective cohort study of >700 subjects. Subjects were matched at a one:two ratio(i.e. one primary closure:two delayed closure patients) on fracture location, Gustilo grade of fracture, age(within five years), significant comorbidities(diabetes, kidney disease and osteoporosis) and social factors(smoking and alcohol abuse). The outcomes were 1) any infection and 2) deep infection within six weeks of surgery. Time on antibiotics and length of hospital stay(LOS) was also recorded. Results. Eighteen primary closure subjects were enrolled between January and May 2010 and matched to 35 delayed closure subjects. The average age of subjects was 4212.6 years and 42(79%) were male. Postoperative infection developed in 0/18(0%) primary closure and 4/35(11.4%) delayed closure subjects within six weeks(p=0.14). Only 1/35 delayed closure subject developed deep infection within six weeks of surgery(p= 0.47). The mean time on antibiotics was 6.82.9 days in primary closure and 7.96.5 days in delayed closure subjects(p=0.50). The mean LOS was 8.47.2 days in the primary closure and 8.16.6 days in the delayed closure group(p=0.88). Conclusion. We found no infection within six weeks postoperatively in the 18 primary closure subjects while four(11.4%) of the matched delayed closure subjects developed infection, one(2.9%) of which was a deep infection. These are promising preliminary results of primary closure of open long bone fractures; further analyses are planned and a randomized trial is under development

Diabetic foot problems are a common cause for hospitalisation in this group and up to 25% of diabetic patients will be affected. Prevalence of diabetes is rising, currently affecting 680000000 people worldwide. The enormity of this problem mandates any strategy that shortens therapeutic period and enhances success rates. Cerament G has been used in our unit as a treatment adjunct in diabetic foot treatment. Successful treatment is viewed as eradication of infection and a functional foot. Retrospective review of 40 months practice with 115 patients. Inclusion: all diabetic feet requiring surgery Cerament G used, protocol driven Microbiology pathway. Exclusion: Primary closure not possible. Cerament G not used. Outcome assessed in three groups: Total failure (further surgery required); slow to heal (healing by secondary intention); healed without problems. Healed 99 (eradication of infection and return to function), failure to heal 16 (success rate: 86.1%). Infection was the cause of failure in only in 2.6% (13 failures due to patient noncompliance or poor vascularity). Accepted success rate in treating osteomyelitis in diabetic feet is 68% (medical treatment only), combination of surgery and medical is 86%. Eradication of infection is the only end point return to function is not addressed. This study shows Cerament G with surgery/systemic antibiotics provides a 97.4% success rate. Therapeutic drivers in this field have been determined traditionally by Physicians and Vascular Surgeons (resection rather than reconstructive surgery.) Our assertion is that eradicating infection in a functionally useless foot is a waste of health resources. Our strategy is always the delivery of an intact functional foot residuum. Cerament G as an adjunct allows this goal in a cost-effective manner

Objectives. Open fracture classification systems are limited in their use. Our objective was to classify open tibia and femur fractures using the OTS classification system in a region with high incidence of gunshot fractures. One hundred and thirty-seven patients with diaphyseal tibia and femur open fractures were identified from a prospectively collected cohort of patients. This database contained all cases (closed and open fractures) of tibial and femoral intramedullary nailed patients older than 18 years old during the period of September 2017 to May 2021. Exclusion criteria included closed fractures, non-viable limbs, open fractures > 48 hours to first surgical debridement and patients unable to follow up over a period of 12 months (a total of 24). Open fractures captured and classified in the HOST study using the Gustilo-Anderson classification, were reviewed and reclassified using the OTS open fracture classification system, analysing gunshot fractures in particular. Ninety percent were males with a mean age of 34. Most common mechanism was civilian gunshot wounds (gsw) in 54.7% of cases. In 52.6% of cases soft tissue management was healing via secondary intention, these not encompassed in the classification. Fracture classification was OTS Simple in 23.4%, Complex B in 24.1% and 52.6% of cases unclassified. The OTS classification system was not comprehensive in the classification of open tibia and femur fractures in a setting of high incidence of gunshot fractures. An amendment has been proposed to alter acute management to appropriate wound care and to subcategorise Simple into A and B subdivisions; no soft tissue intervention and primary closure respectively. This will render the OTS classification system more inclusive to all open fractures of all causes with the potential to better guide patient care and clinical research

Aim. To report outcomes of soft tissue reconstruction using free tissue transfer for the treatment of tibial osteomyelitis as part of a single-stage, ortho-plastic procedure. Method. Patients who underwent ortho-plastic reconstructive surgery to excise tibial osteomyelitis in combination with free tissue transfer in one stage were included. Patients underwent surgery between 2015 and 2024 in a single specialist centre within the UK. Baseline patient information, demographics, and infection information was recorded. Adverse outcomes were defined as (i) flap salvage required, (ii) flap failure and (iii) recurrence of infection. Patient reported quality of life was measured using the EuroQol EQ-5D-5L index score. Pre-operative QoL was compared to QoL at 1 year with a control group of 53 similar patients who underwent surgical treatment for tibial osteomyelitis without a free flap (local flap or primary closure). Results. Ninety-three patients were eligible for inclusion, with a mean age of 52 years (range 18–90). 77/93 (82.8%) had a free muscle flap with the remainder (17.2%) receiving a fasciocutaneous flap. The donor tissue was defined as 57 gracilis, 6 latissimus dorsi, 14 hemi-latissimus dorsi, and 16 anterolateral thigh. The recipient area of the tibia was distal 1/3 in 52 cases, middle 1/3 in 27 cases and proximal 1/3 in 12 cases. The average flap ischaemic time was 70 minutes (range 28 to 125). Seven patients (7.5%) required urgent flap salvage at a median time of 1.0 day (range 0.5 – 4.0). Of these, 4 (4.3%) went on to have total flap failure, of which 2 patients underwent below knee amputation subsequently. Flap failure was due to either arterial (n=2) or venous (n=2) anastomotic thrombus. There were 3 (3.2%) episodes of confirmed infection recurrence within the first year after the index procedure. EQ-index scores at 1-year post-operatively were significantly improved when compared to pre-operative scores (p=0.008). At 1-year post-operatively, EQ-index scores in patients who underwent free flap was similar compared to local flaps (p=0.410) and in those who underwent primary closure for tibial osteomyelitis (p=0.070). Conclusions. Microsurgical single stage surgery can achieve high flap survival rate (95.7%). Free flaps fail early due to anastomotic thrombus with no late failures seen. Free tissue transfer does not appear to give inferior QoL compared to matched patients with local flaps or direct closure in tibial osteomyelitis

Aims. Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Methods. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30). Results. Overall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union. Conclusion. Our multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications. Cite this article: Bone Jt Open 2023;4(7):516–522

Aims. Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up. Methods. A total of 84 patients, with a mean age of 68 years (36 to 92), underwent single-stage revision TKA for confirmed PJI at a single institution between 2006 and 2016. In all, 37 patients (44%) were treated for an infected primary TKA, while the majority presented with infected revisions: 31 had undergone one previous revision (36.9%) and 16 had multiple prior revisions (19.1%). Contraindications to single-stage exchange included systemic sepsis, extensive bone or soft-tissue loss, extensor mechanism failure, or if primary wound closure was unlikely to be achievable. Patients were not excluded for culture-negative PJI or the presence of a sinus. Results. Overall, 76 patients (90.5%) were infection-free at a mean follow-up of seven years, with eight reinfections (9.5%). Culture-negative PJI was not associated with a higher reinfection rate (p = 0.343). However, there was a significantly higher rate of recurrence in patients with polymicrobial infections (p = 0.003). The mean Oxford Knee Score (OKS) improved from 18.7 (SD 8.7) preoperatively to 33.8 (SD 9.7) at six months postoperatively (p < 0.001). The Kaplan-Meier implant survival rate for all causes of reoperation, including reinfection and aseptic failure, was 95.2% at one year (95% confidence interval (CI) 87.7 to 98.2), 83.5% at five years (95% CI 73.2 to 90.3), and 78.9% at 12 years (95% CI 66.8 to 87.2). Conclusion. One-stage exchange, using a strict debridement protocol and multidisciplinary input, is an effective treatment option for the infected TKA. This is the largest single-surgeon series of consecutive cases reported to date, with broad inclusion criteria. Cite this article: Bone Jt Open 2021;2(5):305–313

Compartment syndrome is a devastating complication of limb trauma requiring prompt decompression by means of fasciotomy; however to date little is known about the long term morbidity directly related to the fasciotomy procedure. This is a retrospective study from June 2001 to July 2008 of all patients undergoing fasciotomy in a tertiary referral centre following trauma to a limb. In total this comprised of 66 patients and of these one had since died and five were uncontactable. Therefore 60 patients were surveyed, 48 of whom underwent lower limb fasciotomy and 12 underwent upper limb fasciotomy. Patients were subjected to a phone survey with end points including weakness, parasthaesia and dysasthaesia which had persisted for more than one year post-op. The results were then correlated with time to fasciotomy, site of fasciotomy, initial post-op complications and Methods: of closure. 42 out of 60 patients (70%) reported persistent symptoms. Of these 20 (33%) reported that their symptoms limited them severely either occupationally or socially. Lower morbidity was seen in the upper versus the lower limb fasciotomy group, with decreased incidence of persistent severe symptoms (16.7% versus 35%). Twelve patients had early post-op complications (seven wound infections, 1 cardiac arrest, 2 amputations, 2 haematomas requiring evacuation). Amongst those with post-op complications, 10 out of 12 had persistent symptoms with severe symptoms seen in 80%. In terms of Methods: of closure, 39 patients had delayed primary closure, six were allowed to heal by secondary intention and 15 patients underwent skin grafting. All patients who underwent skin graft were symptomatic at the time of survey with 80% being severely symptomatic. Meanwhile of the patients allowed to heal by seconday intention 83% were asymptomatic. Mean time to closure of fasciotomy was four days. In those patients who were closed in three days or less, 47% were asymptomatic with 23% mildly symptomatic. In the group closed between 8–14 days 37% were symptomatic while all patients closed after 14 days were severely symptomatic. These results demonstrate significant morbidity associated with the fasciotomy procedure. Incidence was highest amongst those undergoing leg or thigh fasciotomy, those who had early post-op complications, those who were closed late and those who were closed with split/ full thickness skin graft. This was most dramatic in those who underwent skin grafting, a vast majority of whom were severely symptomatic. Long term sequelae were lowest in those with upper limb fasciotomies, those undergoing early primary closure and those that were allowed to heal by secondary intention

Aim. The primary aim of multidisciplinary management of diabetic foot disease is limb savage. Difficulty in eradication of infection with systemic antibiotics and obliteration of dead space created by debridement, are two major stumbling blocks in achieving this. Antibiotic loaded bio composites help achieve both these objectives. The aim of this study is to report the early results of antibiotic loaded bio composites in diabetic foot disease. Method. We present early results of 16 patients with diabetic foot disease and osteomyelitis in whom we used antibiotic loaded bio composite (CERAMENT G Bone Support, Lund, Sweden) for local antibiotic delivery and dead space eradication. A multidisciplinary team managed all patients. We performed magnetic resonance and vascular imaging preoperatively and adhered to a strict protocol involving debridement, culture specific systemic antibiotics and dead space obliteration with antibiotic loaded bio composite. The wound was managed with negative pressure wound therapy and all patients were kept non-weight bearing with a plaster back slab or walking boot. Skin cover where required was undertaken by our plastic surgeons. Results. According to the Cierny –Mader Classification 1 patient was type 1, 4 were defined as type 2, 7 were type 3 and 4 were type 4. Seven patients were classed as type B hosts and 9 were type A hosts. At a mean follow up of 38 weeks (26–60) we achieved infection clearance in 14 patients (88%). 10 (63%)wounds healed by secondary intention, 2 had split skin graft, and 1 had primary closure. 2 patients were still on negative pressure wound therapy at final follow-up, one of which has got clearance of infection. One patient is having regular dressings in the community. We had 2 patients who had below knee amputation, one due to significant vascular disease and the other at patient request. Conclusions. A multidisciplinary approach and a strict protocol including augmented debridement and Cerament G injection are effective for treatment of chronic osteomyelitis in diabetic foot disease. The early results with this bio composite antibiotic combination are encouraging

Antibiotic polymethylmethacrylate (PMMA) beads are known as an effective drug delivery system for local antibiotic therapy in bone and soft tissue infections. Over the years it has become an efficient method to treat osteomyelitis and other infections in orthopaedic surgery. Whilst this method has gained popularity primarily in infected arthroplasty, trauma and chronic osteomyelitis, its application in spine surgery is less known. Methods: From 1997 to 2000 we have followed prospectively all patients who developed severe purulent wound infection following various types of instrumented spine fusion. Any patient, who had the typical presentation of surgical wound infection was enrolled into the study. Revision consisted of radical debridement of all necrotic tissue from the surgical wound, jet irrigation with saline and application of antibiotic contained PMMA beads. Primary closure over a suction drain was done in all cases and the patient was treated with parenteral antibiotic therapy. Following first revision, patients were treated with broad-spectrum parenteral antibiotic therapy, which was converted to culture-sensitive antibiotic. Suction drains were removed when the output was less than 50cc/24hr. Patients were returned for a second revision when local and systemic parameters showed no evidence of active infection. This revision consisted of PMMA bead removal, debridement as necessary and irrigation. Primary closure over a suction drain was performed in all cases. No hardware removal was done in any of the cases. Follow up studies included radiographs and gallium bone scan. Results: There were five patients in the study group. Of these, two had posterior spinal fusion for trauma; the remaining three had fusion for a various etiologies (tumor, corrective osteotomy in ankylosing spondylitis and lumbar instability). Causative organism was staphylococcus aureous (2 patients) and MRSA (3 patients). Mean interval from primary surgery to the first revision was 12 days and 19 days until the second revision. None of the patients had a third revision. There was no evidence for exacerbation of the infectious disease during follow up nor any pain or other signs which could mark the beginning of chronic osteomyelitis. No systemic or local complications related to the surgical technique or the PMMA beads were noted during the period between revisions. Galium scan was performed in only three of the five patients for a different reason. Scan results were negative in all three. Conclusion: Two-stage revision surgery with PMMA antibiotic beads in a purulent surgical wound infection following spinal fusion, is a highly efficient method. This approach can assure proper healing of the surgical wound with no need for instrumentation removal or prolonged secondary healing of the surgical

Aim. The optimal surgical approach for patients hospitalized for moderate to severe septic bursitis is not known, and there have been no randomized trials of a one-stage compared with a two-stage (i.e., bursectomy, followed by closure in a second procedure) approach. Thus, we performed a prospective, non-blinded, randomized study of adult patients hospitalized for an open bursectomy. Method. Patients were randomized 1:1 to a one-stage vs. a two-stage surgical approach. All patients received postsurgical oral antibiotic therapy for 7 days. These are the final results of the prospective study registered at ClinicalTrials (NCT01406652). Results. Among 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was one-stage in 79 and two-stage in 85. The two groups were balanced with regards to sex, age, causative pathogens, levels of serum inflammatory markers, co-morbidities, and cause of bursitis. Overall, there were 22 treatment failures: 8/79 (10%) in the one-stage arm and 14/85 (16%) in the two-stage arm (Pearson-χ2-test; p=0.23). Recurrent infection was caused by the same pathogen a total of 7 patients (4%), and by a different pathogen in 5 episodes (3%). The incidence of infection recurrence was not significantly different between those in the one- vs. two-stage arms (6/79 vs. 8/85; χ2-test: p=0.68). In contrast, outcomes were better in the one- vs. two-stage arm for wound dehiscence (2/79[3%] vs. 10/85[12%]; p=0.02), median length of hospital stay (4.5 vs. 6 days), nurses’ workload (605 vs. 1055 points) and total costs (6,881 vs. 11,178 Swiss francs) (all p<0.01). Conclusions. For adult patients with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with 7 days of systemic antibiotic therapy, was safe, resource-saving and effective. Using a two-stage approach did not reduce the risk of infectious recurrence, and may be associated with a higher rate of wound dehiscence than the one-stage approach

Introduction. Recent literature has shown increasing interest in analysing return to theatre (RTT) as a quality indicator across different surgical specialities. The aim of this study is to express “RTT at 90 days” as a useful predictor in identifying complications following primary total knee replacement (TKR). Methods. Patients who had been to theatre within 90 days of primary TKR were identified and their clinical notes were reviewed. Patients’ co morbidities, surgeon's grade, details of revision procedures and their final outcome were analysed. Results. Between 2010 and 2012 a total of 1388 primary TKR were performed. Eleven patients, 11/1388 (0.79%) RTT within 90 days, mean age was 71 years (51 to 85), mean body mass index (BMI) was 30.7 (21 to 45). Out of these 11 patients, six had Manipulation Under Anaesthesia (MUA) for stiffness, two had wound exploration and primary closure and three patients underwent revision arthroplasty following failed salvage procedures. Conclusion. Using RTT as a quality marker, it is possible to assess performance of surgeons and institutions much quicker than with joint registry. Our results showed that RTT at 90 days for TKR in our institution is significantly lower than national average (0.79% versus 1.8%)

Aims

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.