Posttraumatic osteomyelitis (PTO) is a complex condition that results in considerable morbidity. Tibia is one of the most common sites of PTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Developments in surgery have greatly improved the ability to treat this condition. However, some authors defend that functional outcome is often poorer after successful limb reconstruction than after treatment with amputation below the knee, especially in patients with systemic factors that might significantly compromise reconstructive treatment. Limb salvage is associated with a longer convalescence time and a higher risk of complications, additional surgeries, and rehospitalisation. We present a case report of a patient with PTO requiring amputation of the leg despite aggressive surgical treatment. The authors present a case of an 86-year-old woman with past medical history significant for diabetes, hypertension, severe peripheral artery disease and congestive heart failure. In March 2013 the patient sustained a tibia and fibula fracture (42-C1 AO Classification). Closed reduction and intramedullary nailing were performed. Osteomyelitis was diagnosed 1 month later. Implant removal, debridement, stabilization with external fixator and a vascularized skin graft were performed. Graft necrosis with bone exposure occurred after 1 month. Cultures were positive for multiple pathogens, including methicillin-sensitive Staphylococcus aureus. Several surgical debridement, vacuum-assisted closure therapy (VAC) and specific antibiotic therapy were performed for 8 weeks. Clinical deterioration with persistent bacteremia and infectious process led to the amputation below the knee in October 2014. Symptomatic relieve was achieved and C-reactive protein returned to her normal values. Minimal stump necrosis was detected. Seven months postoperatively the patient is doing well with assisted gaitpilaa and few limitations in her daily life and there are no signs of systemic or local infection. Management of posttraumatic osteomyelitis remains a challenge. Amputation may prove to be the most appropriate way of restoring function and improving patient's quality of live, if there is failure to achieve bone healing and restore function. The decision to amputate should be considered carefully and individually, involving both patient and family

Chronic posttraumatic osteomyelitis (CPTO) is a complex condition that results in considerable morbidity and may be limb threatening. Tibia is the most common site of CPTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Adequate soft-tissue coverage is one of the cornerstones in chronic osteomyelitis management. Vacuum-assisted closure (VAC) is frequently used for the treatment of posttraumatic osteomyelitis of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. Free muscle flaps are recommended in distal third tibial defects. We present our experience with two case reports. The authors present two cases of type IIIA osteomyelitis according to Cierny-Mader classification, following previous distal third tibial open fractures. Both patients presented with limb deformity, insidious local pain and chronic purulent discharge (without significant local inflammatory signs) after 11 and 24 years of trauma. They were treated with radical debridement of all nonviable and infected tissue, VAC instillation therapy for 3 weeks and transverse rectus abdominis muscle (TRAM) flap defect coverage. Intra-operative cultures were positive for multiple pathogens. Specific antibiotic therapy was performed for each case for 8 weeks. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values. No complications were documented. 1 year post-surgery, both patients remain asymptomatic, with no signs of infection, with full flap integrity and gait without assistance. Despite the challenging management of chronic posttraumatic osteomyelitis of the tibia, infection control and a satisfactory functional outcome can be achieved. The cornerstones of management include infection control with surgical debridement, microbial-specific antibiotic administration and soft tissue coverage. VAC instillation therapy has an important role promoting granulation tissue formation and infection eradication. The aggressive approach, even with delay on diagnosis, is the key factor for a worthy outcome. Despite the good results, recrudescence of osteomyelitis is known to occur even years after the original offense is treated

A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7).

At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (sd 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (sd 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction.

These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction.

Cite this article: Bone Joint J 2015;97-B:215–20.

Background: Negative pressure wound treatment is increasingly used through a Vacuum-Assisted Closure (VAC) device in complex wound situations. For this purpose, sterile polyurethane (PU) and polyvinyl alcohol (PVA) foam dressings are fitted to the wound size and covered with an adhesive drape to create an airtight seal. Little information exists about the type and quantity of microorganisms within the foams. Therefore, we investigated VAC foams after removal from the wound using a validated method (sonication) to detect the bacterial bioburden in the foam consisting as microbial biofilms. Methods: We prospectively included VAC foams (PU and PVA, KCI, Rümlamg, Switzerland) without antibacterial additions (e.g. silver), which were removed from wounds in patients with chronic ulcers from January 2007 through December 2008. Excluded were patients with acute wound infection, necrotizing fasciitis, underlying osteomyelitis or implant. Removed foams from regular changes of dressing were aseptically placed in a container with 100 ml sterile Ringer’s solution. Within 4 hours after removal, foams were sonicated for 5 min at 40 kHz (as described in . NEJM. 2007. ;. 357. :. 654. ). The resulting sonication fluid was cultured at 37°C on aerobic blood agar plates for 5 days. Microbes were quantified as No. of colony-forming units (CFU)/ml sonication fluid and identified to the species level. Results: A total of 68 foams (38 PU and 30 PVA) from 55 patients were included in the study (median age 71 years; range 33–88 years, 57% were man). Foams were removed from the following anatomic sites: sacrum (n=29), ischium (n=18), heel (n=13), calves (n=6) and ankle (n=2). The median duration of being in place was 3 days (range, 1–8 days). In all 68 foams, bacteria were found in large quantities (median 105 CFU/ml, range 102–7 CFU/ml sonication fluid. No differences were found between PU and PVA foams. One type of organisms was found in 11 (16%), two in 17 (24%) and 3 or more in 40 (60%) foams. Gram-negative rods (Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa) were isolated in 70%, followed by Staphylococcus aureus (20%), koagulase-negative staphylococci, streptococci (8%), and enterococci (2%). Conclusion: With sonication, a high density of bacteria present in VAC foams was demonstrated after a median of 3 days. Future studies are needed to investigate whether antimicrobial-impregnated foams can reduce the bacterial load in foams and potentially improve wound healing

Current treatment modalities for chronic non-healing leg ulcers are time consuming, expensive, and only moderately successful. The use of sub-atmospheric pressure dressings, available commercially as the vacuum-assisted closure (VAC) device, has been shown to be an effective way to accelerate healing of various wounds. There is patented computer-controlled system technology available that is established V.A.C.(KCI Concepts, San Antonio, Texas) treatment. Reducing costs associated with wound treatments is therefore becoming an increasingly important issue in health care. This study included 45 patients with open wounds of the lower extremity with exposed tendon, bone, hardware or with osteomyelitis. Fifteen wounds were the result of trauma. Thirty wounds were non-traumatic (twenty dehisced or infected orthopedic surgical wounds, five pressure sores and five miscellaneous wounds). We use the vacuum therapy as a tool to bridge the period between debridement and definite surgical closure in full-thickness wounds. Treatment efficacy was assessed by semi-quantitative scoring of the wound conditions (signs of rubor, calor, exudate and fibrinous slough) and by wound surface area measurements. In our technique, the system consist of a sterilized simple foam sponge, a vacuum drain, two blood infusion kit and a negative pressure aquarium air pump, one liter salin bottle, an steril drape. It’s mean applying time ten minutes and mean cost at the first time 36 dollars consecutive seances 11 dollars (the aquarium air pump 15 dollars – an electrical engineer change it positive to negative air pressure mode). Forty-five patients who needed open wound management before surgical closure were included in this study. Healing was characterized by development of a clean granulating wound bed (“ready for surgical therapy”) and reduction of wound surface area. To quantify bacterial load, cultures were collected. The total quantitative bacterial load was generally stable. However, nonfermentative gram negative bacilli showed a significant decrease in vacuum-assisted closure-treated wounds, whereas Staphylococcus aureus showed a significant increase in vacuum-assisted closure-treated wounds. Succesfull wound closure was obtained 43 of 45 patients. 41 wounds were closed with split-thicknees skin graft. The median time to complete healing was 31 days (27.5 to 34.5) and wound bed preparation was 7 days (5.8 to 8.2) in the non-computerized V.A.C. therapy, similar with the computerized therapy 29 (25.5 to 32.5–7 days 5.7 to 8.3) This study shows a positive effect of vacuum-assisted closure therapy on wound healing, expressed as a significant reduction of wound surface. The costs of computerized wound care were higher than our techique of V.A.C. and similar clinical results at the end

Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use