Introduction. Infection following TKA can be a catastrophic complication that can cause significant pain, morbidity and jeopardize limb viability. The integrity of the soft tissue envelope is critical to successful treatment and infection control. While local tissue flaps can provide adequate coverage for most soft tissue defects around the knee, there are cases that require salvage using microvascular free tissue transfers. The purpose of this study is to evaluate the 1) rate of limb salvage; 2) infection control; and 3) clinical function following free flap coverage for salvage of the infected TKA. Materials and Methods. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and 7 women with a mean age of 61.2 years (range 39–81). The median number of procedures performed prior to soft tissue coverage was 5 (range 2–9) and all patients had failed at least one 2 stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. The rate of limb salvage and infection control were recorded. Results. One patient was lost to follow up prior to 12 months. The remainder 22 patients were followed for a mean of 46 months (range 12–92 months). At latest follow up, 4 patients (18%) had undergone amputation for failure of treatment and persistent infection. For the remainder 18 patients, 11 patients (50%) have maintained a knee prosthesis in place while 7 patients had undergone resections for persistent infection but maintained their limbs (32%). Reoperations were common following coverage and reimplantation procedure. The median number of additional procedures was 2 (range 0–6). Clinical function was poor in patients who were reimplanted and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (range 0–70) and 30 (range 0–65). All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. Conclusions. Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (81%) but clinical outcomes in salvaged limbs were poor. The data should be used to counsel patients when contemplating limb salvage in these severe, end-stage cases. For figures, tables, or references, please contact authors directly

The aim of this study was to perform a systematic review of the literature on Gustilo-Anderson (GA) type IIIB open tibial shaft (AO-42) injuries to determine the consistency of reporting in the literature.

A search of PubMed, EMBASE and Cochrane Central Register of Controlled Trials was performed to identify relevant studies published from January 2000 to January 2021 using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The study was registered using the PROSPERO International prospective register of systematic reviews. Patient/injury demographics, management and outcome reporting were recorded.

There were 32 studies that met the inclusion criteria with a total of 1,947 patients (70.3% male, 29.7% female). There were 6 studies (18.8%) studies that reported on comorbidities and smoking, with mechanism of injury reported in 22 (68.8%). No studies reported on all operative criteria included, with only three studies (9.4%) reporting for time to antibiotics, 14 studies (43.8%) for time from injury to debridement and nine studies (28.1%) for time to definitive fixation. All studies reported on the rate of deep infection, with a high proportion documenting union rate (26/32, 81.3%). However, only two studies reported on mortality or on other post-operative complications (2/32, 6.3%). Only 12 studies (37.5%) provided any patient reported outcomes.

This study has demonstrated a deficiency and a lack of standardized variable and outcome reporting in the orthopaedic literature for Gustilo-Anderson type IIIB open tibial shaft fractures. We propose a future international collaborative Delphi process is needed to standardize.

Introduction and Objectives: Our aim is to describe the versatility of the Becker flap in different pathological conditions of the hand as treated in a orthopaedic trauma centre.

Materials and Methods: The Becker flap surgical technique is described as it is used in our centre as a means for coverage of injuries of the soft tissues in the palmar region of the hand. The procedure is described in three patients. One of these was a salvage procedure for recurrent carpal tunnel syndrome. The second was performed after an acute infection of the hypothenal eminence. The third involved coverage of a hand following trauma with a loss of tissue.

Results: In spite of the varied aetiologies of these cases, coverage was complete in all three cases, and there was no vascular compromise of the flap, nor dehiscence of sutures or acute infections. The use of the cubital flap was sufficient to resolve these conditions. On follow up, overall functional results for the hands were good, and the aesthetic results were acceptable for both the hand and the donor site.

Discussion and Conclusions: The Becker flap represents a good option for coverage of palmar cutaneous defects of the hand. Its versatility in the field of orthopaedic trauma makes it a practical and efficacious flap for use in acute and delayed cases.

Aim. Pin site infection (PSI) is a common complication of external fixators. PSI usually presents as a superficial infection which is treated conservatively. This study investigated those rare cases of PSI requiring surgery due to persistent osteomyelitis (OM), after pin removal. Method. In this retrospective cohort study we identified patients who required surgery for an OM after PSI (Checketts-Otterburn Classification Grade 6) between 2011 and 2021. We investigated patient demographics, aetiology of the OM, pathogen and histology, treatment strategies and complications. Infection was confirmed using the 2018 FRI Consensus Definition. Successful outcome was defined as an infection-free interval of at least 24 months following surgery, which was defined as minimum follow-up. Results. Twenty-seven patients were treated due to a pin site infection with an osteomyelitis (22 tibias, 2 humeri, 2 calcanei, 1 radius). 85% identified as male and the median age was 53.9 years. Eighteen infections followed external fixation of fractures, with 4 cases after Ilizarov deformity correction, 2 cases followed ankle fusion and 3 after traction pin insertion. Fifteen patients were classified as BACH Uncomplicated and 12 were BACH Complex. The median follow-up was 3.99 years (2.00–8.05 years). Staphylococci were the most common pathogens (16 MSSA, 2 MRSA, 2 CNS). Polymicrobial infections were present in 5 cases (19%). All surgery was performed in a single stage following the same protocol at one institution. This included deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. Seven patients required flap coverage (6 local, 1 free flap), which was performed in the same operation. 25 (93%) patients had a successful outcome after one surgery. Two had recurrence of infection which was successfully treated by repeat of the protocol. One patient suffered a fracture through the operated site after a fall. This healed without infection recurrence. Wound leakage after local antibiotic treatment was seen in 3/27 (11%) of cases. All resolved without treatment. After a minimum of 2 years follow up, all patients were infection free at the site of the former osteomyelitis. Conclusions. OM after PSI is uncommon but has major implications for the patient as 7 out of 27 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections require appropriate surgery, not just curettage. All patients in our cohort were infection-free after a minimum follow-up of 2 years suggesting that this protocol is effective

Aim. A number of orthopaedic strategies have been described for limb salvage following periprosethic joint infection (PJI). However, this is often only possible with concomitant soft tissue reconstruction in the form of flap coverage. The purpose of this study was to determine the long-term clinical outcome of patients who underwent pedicled gastrocnemius flap coverage as part of their treatment for knee PJI. Method. We performed a retrospective review of all patients undergoing gastrocnemius muscle transfer with split thickness skin grafting as part of their treatment for knee PJI at a tertiary referral centre between 1994 and 2015. Data recorded included patient characteristics, orthopaedic procedure, microbiology result and antimicrobial management. Outcome measures included flap failure, infection recurrence, amputation, functional outcome (Oxford knee score; OKS) and mortality. Results. In total, 115 consecutive patients (39% female) with a mean age of 74.4 years (range 44–100) were followed up for an average of 5.5 years (range 119 days – 19.7 years). There were no reported cases of flap failure. Gastrocnemius flaps were most commonly performed at the time of the first stage of a two-stage revision (41%), or during debridement and implant retention (DAIR) (27%). 10% were performed at the second stage of a two-stage procedure and 4% were performed during a single stage revision. Of 96 positive deep specimen cultures, 43 (45%) showed mixed growth and 47 (49%) grew coagulase-negative staphylococcus (with or without other microorganisms). The infection recurrence rate was 32%. Limb salvage was achieved in 88% of cases. 12% of patients required life-long suppressive antibiotic therapy. 55 knees were followed up for five years or more, with a survival (not deceased, not amputated) of 64%. 37 knees were followed up for 10 years or more, with a survival of 32%. In living patients who did not have an amputation, the mean OKS was 25.8 (n=36; range 7–47). Conclusion. This study represents the largest series to date of infected knee prostheses treated with gastrocnemius flap coverage. A multidisciplinary approach to complex PJI surgery is recommended, involving infectious disease physicians and the orthoplastic team. We also recommend a low threshold for requesting plastic surgery input. In our experience, this technique is safe, with no flap failure, and has enabled limb salvage for the majority (88%) of patients with infected knee prostheses and insufficient soft tissue envelope

Evaluation of the surgical approach and treatment outcomes in patients with chronic osteomyelitis of the tibia classified as anatomic type 3 and 4, physiologic class B (Cierny-Mader). Analysis of surgical treatment of 68 patients (average age of 45.6 years) with chronic osteomyelitis of the tibia covered the period from June 1, 2013 till January 1, 2015. There were 49 males (72%). The first (I) group included 39 patients with type 3 chronic osteomyelitis of the tibia, the second (II) group – 29 patients with type 4 osteomyelitis. The follow-up was for 1–18 months. Duration of the surgery, intraoperative blood loss, causes of osteomyelitis and the frequency of infection recurrence were evaluated. In the group I, 33.3% of patients underwent debridement of the infected site and replacement of the bone defect with an antibiotic-laden cement spacer. In 28.2% of cases, a biodegradable antibiotic delivery system was used for the replacement. 23.1% of cases involved muscle flap coverage of the bone and tissue defect, while 15.4% – treatment with external fixation. In the group II, the proportion of cases treated with external fixation was 58.6%. It was higher than in group I (p<0.01). 27.6% of patients in this group had their defects replaced with an antibiotic-laden cement spacer, whereas 10.3% had muscle flap coverage. One patient had amputation of the tibia. Duration of the surgery and blood loss in group II was 2.4 and 1.7 times higher than in group I. The frequency of infection recurrence in both groups was comparable (about 13%). The average time of its manifestation was 20.8 days in group II and 41.6 days in group I. Infection recurrence after muscle flap coverage was not observed. S.aureus was the most common pathogen in both groups (50–60%). Microbial associations were isolated in 28.3 and 38% of cases in groups I and II, respectively. 33.3% of patients experienced infection caused by P.аeruginosa. Differences in the blood loss and duration of the surgery were due to the larger volume of the affected tissues in type 4 chronic osteomyelitis of the tibia. High frequency of infection recurrence was observed in patients with microbial associations and P.aeruginosa. The surgical treatment of choice for these patients might be muscle flap coverage. It is necessary to consider the type of a pathogen for systemic and local antimicrobial therapy

To describe clinical situations for use of modified VAC in POC based on: diagnosis, comorbidities, BMI, wound size in cm, days following trauma when VAC was first applied, total duration of uninterrupted use, frequency of change, settings, bacterial growth, outcomes. To report the outcomes of mVAC use in POC within 6 months to help improve and standardize its application in the institution. This study involves data gathering from inpatients handled by orthopedic surgeons in training and subspecialty rotations in POC. The data collected are highly dependent on the doctors-in-charge's complete charting, thorough reporting and accurate documentation. Modified Vacuum Assisted Closure (mVAC) is used frequently in this study and is defined as a form of revised, adapted and reformed use of VAC based on available materials in the involved institution. The materials that are included are, but not limited to the following: sterile Uratex™ blue foam, nasogastric or suction tubing, phlegm suction machine, Bactigras™ and Opsite™ or Ioban™. A total of 58 patients were included in the study. The average age of the population was 35 and are predominantly male. The most common mechanism of injury was motorcycle accident and 37 of the patients were diagnosed with an open fracture of the lower extremity with open tibia fractures (22) being the most common. Average wound area measured was 24.12 cm. 3. All patients yield a bacteria growth with e. coli being the most frequent. Average during of uninterrupted use was 39 days. Of the 58 included in the study, 8 patients underwent STSG, 2 had a flap coverage surgery, 4 patients eventually underwent amputation and 33 with complete resolution of soft tissue defect after conversion to biologic dressing post-mVAC. The rest of the population were still ongoing mVAC at the end of the study. mVAC is an alternative temporary medium for soft tissue coverage for cases with or without concomitant fractures. mVAC promotes removal of exudate from the wound, supports wound apposition and granulation bed proliferation. Usage mVAC helps prepare for skin coverage procedure and on some cases leads to full resolution of defect

Introduction. While knee arthrodesis is a salvage option for recalcitrant total knee arthroplasty (TKA) periprosthetic joint infection (PJI) it is used relatively uncommonly and contemporary data are limited. We sought to determine the reliability, durability and safety of knee arthrodesis as the definitive treatment for complex, persistently infected TKA in a modern series of patients. Methods. We retrospectively identified 41 knees treated from 2002–2016 with a deliberate, two-stage knee arthrodesis protocol (TKA resection, high-dose antibiotic spacer, targeted IV antibiotics and followed by subsequent knee arthrodesis) in patients with complex TKA PJI. Mean age was 64 years & mean BMI was 39 kg/m. 2. Mean follow-up was 4 years. The extensor mechanism was deficient in 66% of knees, and flap coverage was required in 34% of knees. The majority of patients were host grade B (56%) or C (29%), and extremity grade of 3 (71%). Twenty-nine percent had poly-microbial infections, and 49% had multi-drug resistant organisms. Fixation included intramedullary nail (61%), external fixator (24%), and dual plating (15%). Results. Two patients (5%) required amputation for persistently infected non-unions; therefore, limb salvage was accomplished in 95% of patients. After initial treatment, there were non-unions in 24% and persistent infection in 17%. Non-union was significantly correlated with persistent infection, with 50% of non-unions having persistent infection compared with just 6% of united knees (p=0.006). External fixation was a significant risk factor for non-union (70%) compared to intramedullary fixation (8%; p=0.005). Overall, twenty-seven complications occurred in 20 patients and 31% required reoperation other than external fixator removal. Intramedullary fixation led to a 90% rate of both infection control and radiographic union. Conclusion. Two-stage knee arthrodesis using a deliberate protocol (resection, high-dose abx spacer, targeted IV abx, and subsequent arthrodesis) ultimately achieved successful limb salvage in 95% of patients with complex infected TKA. One or more complications occurred in nearly half the patients and reoperation was required for 1-in-3. That substantial risk of complications is not surprising as this large contemporary series included complex, worst-case infected TKA in which: 2/3 had disrupted extensor mechanism, 1/3 required flap coverage, and the majority had poly-microbial or multi-drug resistant organisms. Summary. For contemporary patients with very complex, infected TKA a two-stage knee arthrodesis was reliable in achieving limb salvage (95%) at the cost of a high initial complication and reoperation rate. For figures, tables, or references, please contact authors directly

Purpose: Total knee arthroplasty is an effective treatment for arthritis, even in post-traumatic situations. However, the final results in this specific etiology are poorer than in degenerative cases. Difficulties come from intra-articular involvement of the initial fracture leading to articular bone defects, joint stiffness, capsula and ligaments retraction, various previous skin incisions with wound complications, and younger more demanding patients. Even the knee artrhoplasty device may be different from degenerative situation. Material and Methods: We report a retrospective series of 11 knee prostheses implanted from 1995 to 2007 in post-traumatic cases with intra-articular malunion due to the initial fracture. Review of the procedures included type of previous incisions, number and type of flap coverage, amount of articular release, specific knee artrhoplasties (hinged or postero-stabilized), and final outcome based on IKS score. Results: In all cases but one, the prosthesis gave a better result on mobility compared to pre-op function. Pain relief was obtained in all cases. In one case, removal of the prosthesis was needed due to infection. In 8 cases, flap coverage was done previously or simultaneously to arthroplasty implantation. Technical tricks are emphasized based on complications listed. Discussion: Results of total knee arthropplasty in post-traumatic cases are poorer than in degenerative situations. Additional techniques are mandatory such as bone graft, flap coverage, and extensive articular release. Computer assisted surgery is helpful in severe angular deformity or complex post-trauma ‘anatomy’

Aim. A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated. Method. Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis. Results. Sixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly plurimicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p=0.022). An increased prevalence of coagulase negative Staphylococci (p=0.017) and Candida (p=0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p=0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p=0.025) and Actinomyces infection (OR, 9.5; p=0.027). Conclusions. Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. Carbapenem should be reserved for ESBL at-risk patients only, including those with previous fluoroquinolone use. The uncorrelation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment

Introduction. Osteomyelitis (OM) is a challenging condition to diagnose and treat. The multidisciplinary team (MDT) approach is used in managing complex diseases such as cancer and diabetes. The Hull Regional Bone Infection MDT team was established to provide coordinated care for patients suspected to have OM. This study reviews the orthoplastic treatment and outcomes of patients with non-periprosthetic OM. Materials and Methods. Retrospective review of patients presenting to the MDT team who had orthoplastic intervention with debridement and flap coverage between 1/6/2014 - 30/11/2018. We describe our MDT approach of assessment, planning for surgical intervention and antibiotic protocol. Data was obtained from electronic and paper patient records, and PACS. Results. Twenty-nine patients were identified (75.9% male). Mean age was 52.7 (23–82). Median duration of symptoms at surgery was 10 months (IQR 4.0–34.3). Cierny-Mader (CM) Host Type B. (L). (41.4%), type B. (S). (34.5%), and type B. (S+L). (17.2%). Twenty-four patients (82.8%) were CM anatomical class IV. Twenty-four patients (82.8%) had single-stage surgical treatment. Twenty-one patients received 23 free flaps. Anterolateral thigh flap (9/23) and gracilis muscle flap (7/23) were most commonly used. Tibialis anterior flap was the most commonly used local flap. Stimulan was used in 65.5%. Staphylococcus aureus was seen in 60% of patients. Mean follow-up time was 21 months (1–62). There were 2 (6.9%) OM recurrence. Both patients were CM anatomical class IV. Conclusions. Our study showed that our MDT management of patients with OM can achieve a low recurrence rate despite a high proportion of patients with severe OM. We recommend considering an MDT approach for these complex OM patients

Introduction. The purpose of this study is to evaluate the early functional outcome and activity level in athletes and soldiers with large full thickness cartilage defects of the knee that underwent either ‘classic’ autologous chondrocyte implantation using periosteal flap coverage (ACI-P) or 3-D matrix-assisted chondrocyte implantation (ACI-M). Methods. Between April 2002 and January 2004, 19 patients (15 male, 4 female, average age 32.2 years) with 22 full-thickness cartilage defects in 19 knees were treated with ACI in our centre. The mean post-injury interval was 39.8 months whereas 17 (89.5%) patients had undergone at least one surgical procedure before ACI. The average defect size was 6.54 cm. 2. (located in MFC:7, LFC:7 or trochlear:2 while 3 patients had bifocal lesions in both LFC and TRC). Novocart. ¯. cultured chondrocytes with periosteal flap coverage were used in 11 patients and Novocart-3D. ¯. cell impregnated collagen patch in 8. The functional outcome was evaluated with IKDC form, Tegner activity scale and Lysholm score after a mean follow-up period of 26.5 months. Results. The average IKDC and Lysholm scores were improved from 39.16 and 42.42 pre-operatively to 62.4 and 69.4 at the latest follow-up respectively. The mean Tegner activity scale was 8.73 before injury, 3.63 pre-operatively and 5.21 at the latest follow-up. There was no statistically significant difference between the two groups regarding the clinical outcome and the overall athletic or military performance. Second-look arthroscopy was performed in 11 (57.8%) patients due to persistent pain and/or mechanical symptoms. Generally, the ACI site showed adequate graft integration except for one partial failure. Conclusions. The early results of ACI in high-performance athletes and professional soldiers are not as good as other recent studies suggest. Motivational issues during prolonged rehabilitation, patient age and very large defects may influence early results in this select group of patients

This study documents the use of bone graft harvested by the RIA system and used in treating segmental bone loss in the femur and tibia following trauma. Eight patients with segmental defects of the tibia or femur were enrolled in the study. The segmental defects were optimized for bone grafting by repeated debridements and muscle flap coverage as required. Graft was harvested from the ipsilateral femur via a percutaneous technique. Volumes of bone graft were recorded and then placed to the defect site during the same surgical procedure. The average age of the patients was twenty-nine years (sixteen to forty-one years). In the five tibiae and three femora there were four grade IIIA, three grade IIIB and One grade IIIC injuries. Muscle flap coverage was required in four patients. The average size of defect was 7 cm (1–14.5 cm). The RIA grafting was performed at an average of three months (2.5 – 5 months) post injury. The average bone graft volume obtained was 73cc(45–90 cc). The average hemoglobin drop was 4.4g/dl(2.3 – 8.0 g/dl) and the average hematocrit drop was 12.3%(6–21%). One patient required transfusion. Donor site complications were limited to one post-operative bleed. Defect site complications included one wound dehiscence and two infections. Radiographic union of the defects was achieved at an average time of four months (two to twelve months). Grafting of large segmental defects using RIA bone graft has resulted in union at an average of four months. This technique represents an alternative to bone transport for treatment of segmental defects. Reamed Irrigation Aspirator (RIA) allows access to large volumes of bone graft from the femur through percutaneous technique. The grafting technique was utilized to obtain graft for eight segmental defects in the tibia and femur. These healed at an average of four months

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the healthcare system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with 2-year cumulative risks of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown postoperatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastic surgery is associated with increased rates of prosthesis retention and limb salvage

Aim. Duration of perioperative antimicrobial prophylaxis (PAP) remains controversial in prevention of fracture-related infection (FRI) – with rates up to 30% - in open fracture (OF) management. Objectives were to investigate the impact of the PAP duration exclusively in or related to long bone OF trauma patients and the influence of augmented renal clearance (ARC), a known phenomenon in trauma patients, as PAP consists of predominantly renally eliminated antibiotics. Method. Trauma patients with operatively treated OF, admitted between January 2003 and January 2017 at the University Hospitals Leuven, were retrospectively evaluated. FRI was defined following the criteria of the consensus definition of FRI. A logistic regression model was conducted with FRI as outcome. Results were considered statistically significant when p< 0.05. Results. Forty (8%) from the 502 patients developed a FRI, with 20% FRIs in Gustilo-Anderson (GA) III OFs. Higher GA grade and polytrauma were independently associated with the occurrence of FRI. The heterogeneity in OF management, especially with regard to the applied PAP regimens and duration, was striking and consequently hampering the investigation on the impact of PAP duration. To overcome this issue, a subgroup analysis was performed in patients treated with the two PAP regimens as defined in the hospitals' guidelines – i.e. cefazolin, with metronidazole and tobramycine when extensive contamination was present -, revealing flap coverage and relative duration of augmented renal ARC as independently associated factors. Conclusions. For the first time, a definition based on diagnostic criteria was used to objectively include patients with a FRI. In order to support clinicians in establishing strategies to prevent FRI in long bone OFs, further prospective large randomized controlled trials with clearly predefined PAP regimens are needed to provide reliable recommendations regarding the impact of duration of PAP and ARC

Aim. The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality. Method. This is a single-center retrospective review of routine hospital data from 21 patients (15 men, 6 women, median age 65 [range, 21 to 87] years) undergoing IMN arthrodesis of the hindfoot for post-traumatic infections between January 1st, 2012 and March 15, 2018. We observed four bimalleolar, eight trimalleolar, three pilon fractures, and six distal lower leg fractures. Six and three patients had sustained second- and third degree open fractures, respectively. Early- and late-onset surgical infections were observed in 8 and 13 cases. Four participants had diabetes mellitus, two arterial occlusive disease, and four had both. Six patients were smokers. Results. Intraoperative cultures before implanting the nail revealed staphylococcus aureus in 12, staphylococcus epidermidis in five, and enterococcus faecalis in eight cases. After a median follow-up of 21 months, infection was considered cured in 19 / 21 subjects (90%, 95% confidence interval 70 – 99%). Soft tissue comminution required coverage with a suralis flap in five patients, and with a latissimus dorsi flap in another three. Mesh graft was necessary in 8 / 21 reconstructions. Conclusions. Tibiotalocalcaneal fusion by IMN is an effective salvage procedure for post-traumatic ankle infections. Arthrodesis and definitive wound closure or plastic flap coverage can be performed as single-stage surgery. By resecting the prominent distal fibula, lateral soft tissue defects can be managed more easily. The small sample size prohibited a more detailed analysis of exposure variables, but 8 / 13 patients in this cohort had at least one known risk factor for infection and prolonged healing

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the health care system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with a 2-year cumulative risk of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown post-operatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastics surgery is associated with increased rates of prosthesis retention and limb salvage

Introduction. The burden of peri-prosthetic joint infection (PJI) following hip and knee surgery is increasing. Endoprosthetic replacement (EPR) is an option for management of massive bone loss resulting from infection around failed lower limb implants. Aims. To determine clinical outcome of EPRs for treatment of PJI around the hip and knee joint. Methods. This was a retrospective consecutive case-series of hip and knee EPRs between 2007–2014 in our tertiary unit for the treatment of PJI following complex arthroplasty or fracture fixation. Data recorded included indication for EPR (infected primary/revision arthroplasty, infected non-union/failed osteosynthesis, gross bone loss following native joint infection), number of previous surgeries, and organism identified. Outcome measures included PJI eradication rate (with failure defined as EPR revision, amputation, or being on life-long suppressive antibiotics), complications, implant survival, mortality, and functional outcome (Oxford Hip/Knee Score; OHS/OKS). Results. 58 EPRs (32 knee and 26 hip) were performed with a mean age of 68 years (range: 35–92). The mean number of previous surgeries prior to EPR was 3.4 (range: 1–10). At mean follow-up of 3.5 years, 11 (19%) patients were deceased. EPR was implanted as a two-stage procedure in 76% of cases. Plastic surgical involvement and flap coverage was necessary in 11 cases. Polymicrobial growth was detected in 40% of cases, followed by Coagulase-negative staphylococci (26%). The overall complication rate was 40%. Recurrence of infection post-EPR occurred in 14 patients (24%); 5 were treated with Debridement, Antibiotics and Implant Retention (DAIR), 3 with revision, 1 with above-knee amputation and the remaining 6 remained on long-term suppressive antibiotics. PJI eradication was achieved in 44 (76%) cases (69% knees and 85% hips). Of the remaining 14 cases, 9 remain on long-term antibiotics. The complication rate was similar in knees (41%) and hips (38%). PJI eradication was more successful in hips (85%) compared to knees (69%). To date, 6 EPRs have been revised (10%). The overall 5-year implant survivorship was 83% (95% CI: 68–98%). The mean OHS was 25 (range 7–39.) and the mean OKS was 20 (range 6–43), the best possible score being 48. Conclusions. This mid-term study provides further support for the use of massive endoprostheses in the eradication of PJI in complex, previously multiply revised cases with subsequent limb salvage (in all but one case). We describe PJI eradication rate of 76% with acceptable functional outcomes. This eradication rate is comparable to that following treatment of PJI associated with standard arthroplasty

Treatment of open fractures is complex and controversial. The purpose of the present study is to add evidence to the management of open tibial fractures, where tissue loss necessitates cover with a free flap. We identified factors that increase the risk of complications. We questioned whether early flap coverage improved the clinical outcome and whether we could improve our antibiotic treatment of open fractures. From 2002 to 2013 we treated 56 patients with an open tibial fracture covered with a free flap. We reviewed patient records and databases for type of trauma, smoking, time to tissue cover, infection, amputations, flap loss and union of fracture. We identified factors thatincrease the risk of complications. We analyzed the organisms cultured from open fractures to propose the optimal antibiotic prophylaxis. Follow-up was minimum one year. Primary outcome was infection, bacterial sensitivity pattern, amputation, flap failure and union of the fracture. When soft tissue cover was delayed beyond 7 days, infection rate increased from 27% to 60% (p<0.04). High-energy trauma patients had a higher risk of amputation, infection, flap failure and non-union. Smokers had a higher risk of non-union and flap failure. The bacteria found were often resistant to Cefuroxime, aminoglycosides or amoxicillin, but sensitive to Vancomycin or Meropenem. Flap cover within one week is essential to avoid infection. High-energy trauma and smoking are important predictors of complications. We suggest antibiotic prophylaxis with Vancomycin and Meropenem until the wound is covered in these complex injuries. The authors wish to thank Christian E Forrestal for secretarial assistance, spreadsheets and figures, MD Maria Petersen for academic feedback and typography. Table: Culture results. Depicts the organisms isolated from the wounds, their number N and the number of bacteria that were fully susceptible to antibiotics according to the culture results in falling order on day 2–30 from the trauma. Most organisms were resistant to Cefuroxime. A blank space denotes that the organism was not tested against this antibiotic. A “0” denotes that the organism was not fully sensitive to the antibiotic

Aims

This study was designed to characterize the recurrence incidence and risk factors of antibiotic-loaded cement spacer (ALCS) for definitive bone defect treatment in limb osteomyelitis.