Introduction

Success rate after Debridement-Irrigation, Antibiotic Therapy and Implant Retention (DAIR) for treatment of Acute Haematogenous (AH) and Early Post-surgical (EP) periprosthetic joint infection (PJI) varies widely among published studies. Prosthesis exchange is recommended to treat PJI after a failed DAIR. However, no early postoperative prognostic factors permitting to identify future failures have been described.

Aim

Infections in long bones can be divided in osteitis, osteomyelitis and septic non-unions. All are challenging situations for the orthopaedic surgeon. Treatment is a mix with debridement, radical resection of infected tissue, void filling with different types of products, and antibiotic therapy of different kinds. In cavitary bone defects, bioglasses such as BAG-S53P4 have given good results in early or mid-term follow-up. Results of such treatment in segmental bone defects remain unknown. The goal of our study was to evaluate efficacity of active bioglass BAG-S53P4 in septic segmental bone defects.

Post-traumatic synostosis of the forearm are challenging situations after elbow trauma, injuries of the forearm or the wrist. According to Vince or Hastings classification, therapeutic options are still controversial, due to an unpredictive outcome with recurrence of the synostosis or progressive loss of mobility from post-op to definitive situations.

A retrospective study of 13 cases, including 3 Vince Type 1, 6 Vince Type 2 and 4 Vince type 3 with a minimum follow-up of 3 years was analyzed as well as a review of 47 worldwide publications for defining the optimal therapeutic options. All data files were reviewed including extensive analysis of the CT-scans, and detailed surgical procedures.

For Vince 1 synostosis, in post-traumatic situations, Sauve-Kapandji procedure give excellent or good results when no recurrence of the synostosis is seen. Instability of the proximal ulna after segmental resection is the major complication to be described. In Vince 2 synostosis, an extensive resection of the synostosis is mandatory to obtain a potential good result. Knowledge of the entire anatomy of the forearm is needed for accurate neurolysis of radial nerve and branches. The ulnar approach to the synostosis must be completed with an anterior approach to the radius for a complete resection. In Vince 3 synostosis, resection is easy but recurrence is frequent, due to the associated lesions of the elbow. Based on the litterature review, no additive treatment is necessary for better results Therapeutic options in post-traumatic synostosis of the forearm is a rare complications of elbow lesions (Vince 3), forearm comminutive or complex fractures (Vince 2), or wrist injuries (Vince 1). The latter give the more predictable results after complete resection. Elbow lesions associated with radio-ulnar synostosis are easy to treat but with important recurrence rate, whatever treatment was done. Vince 2 post-traumatic radio-ulnar synostosis are the most challenging situation as bone resection must be extensive meanwhile neurolysis of forearm nerves must be done in the same time. No adjuvant treatment is indicated in either situation according to Vince classification.

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’.

Purpose: Wound defects management during or after a total knee arthroplasty is a challenging clinical situation which raises the risk of implant exposure and infection with subsequent removal and poor functional outcome. The clinical course of the tissue loss is unpredictable leading to retarded curative treatment.

Material and Methods: We report a consecutive retrospective series of 39 knee prostheses implanted from 1990 to 2007 where a wound defect occured during or after implantation of a total knee arthroplasty. Salvage surgery have included a flap with different way of treatment for the knee prosthesis. We studied time to onset of tissue loss, wound border vitality, presence or absence of implant exposure, type of cover flap distinguishing faciocutaneous and muscle flaps, retention or not of the implant, and time of secondary reconstruction.

Results: In 34 of the 39 prostheses, the implant use of the cover flap enabled saving the implant and proper wound healing. In 2 additional cases, wound closure using a flap enabled a reimplantation of a knee prosthesis. The joint remained functional but only 20 knees recovered flexion greater than 90°. In three cases, the implant had to be removed and a knee arthrodesis was done, in all cases due to infection with resistant bacteria (staphylococcus, serratia). Prognositic factors identified included: time from tissue loss to its treatment, usefulness of a cover flap to save the implant, or usefulness of two-procedure reconstruction in case of implant infection.

Discussion: We compared our therapeutic methods with the propositions in the Laing classification and preferred to distinguish a simplified three-step tactic based on time of exposure for determining the theraputic strategy for cutaneous tissue loss in knee prosthesis patients.