The critical relationship between airborne microbiological contamination in an operating theatre and surgical site infection (SSI) is well known. The aim of this annotation is to explain the scientific basis of using settle plates to audit the quality of air, and to provide information about the practicalities of using them for the purposes of clinical audit. The microbiological quality of the air in most guidance is defined by volumetric sampling, but this method is difficult for surgical departments to use on a routine basis. Settle plate sampling, which mimics the mechanism of deposition of airborne microbes onto open wounds and sterile instruments, is a good alternative method of assessing the quality of the air. Current practice is not to sample the air in an operating theatre during surgery, but to rely on testing the engineering systems which deliver the clean air. This is, however, not good practice and microbiological testing should be carried out routinely during operations as part of clinical audit. Cite this article: Bone Joint J 2024;106-B(9):887–891

Background. Open fracture wounds are well known to be associated with infection & prolonged healing. Activity in scientific research to improve wound healing has often provided variable results. This study was done to question the de facto nature of Normal Saline as best irrigant in management of such wounds and to find out a better irrigant, if so, that does exist with due consideration to the mechanism by which saline dressings act. Material and methods. 30 patients with Grade 3 open fracture wounds were assessed over a period of three months according to Ganga Hospital Injury severity Score and were divided equally in study and control groups after adequate matching. A standard dressing protocol consisting of debridement and external fixation within 6 hours, avoidance of any antiseptic or surfactant agent, high-volume low-pressure pulsatile lavage irrigation and saline soaked gamgee pad packings with concerned solutions changed twice daily was done in respective groups. Follow-up was done by colour of healing granulation tissue, pus culture and soft tissue biopsy at Day 1, 3,7,10 & 14. Results. 6 out of 15(40%) wounds in study group were observed to have reached pink healthy granulation with low exudate by Day 14 as compared to only 3 out of 15(20%) in control group. The time taken to traverse from each stage of healing granulation was also observed to be smaller with 3% NaCl as compared to 0.9% NaCl. Although once healthy granulation stage was reached, further dressing with 3% NaCl in study group was shown to have worsening of granulation in about 33% of cases with none such observed in control. Conclusion. 3% NaCl is a better irrigant than 0.9% NaCl for dressing of Open trauma wounds during initial stages of dressing. Their effectivity in maintaining advanced granulation is although questionable, probably owing to its desiccative action

Aims. Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries. Methods. This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation. Results. Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes. Conclusion. The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963–971

Abstract. Aims. The primary aim of this study was to evaluate the outcomes of fungal knee periprosthetic joint infection following knee arthroplasty. The secondary aim was to evaluate risk factors for acquiring a fungal PJI. Patients and Methods. This was a retrospective analysis of patients presenting with a confirmed fungal PJI of the knee in two tertiary centres. There were a total of 45 cases. Isolated fungal infections along with mixed bacterial and fungal infections were included. Mean follow up was 40 months (range 3–118). Results. The mean age at presentation was 69 years (range 46 to 87) and mean BMI was 31 kg/m2 (range 20 to 44). The median number of procedures that patients had on the affected limb from the index primary arthroplasty procedure was 6 (range 2–17). The median procedure number at which a fungal infection was identified was 5 (range 2–10). A history of prolonged antibiotic therapy (above 6 months total) was present in 37 patients (88%). During the study period 22 patients were infection free, 14 treated with lifelong suppression, 7 had above knee amputations and 6 had died. Overall infection cure rate was 49%. Conclusions. Patients with fungal PJI are generally poor hosts with multiple co-morbidities, long term exposure to antibiotics and high rates of open wounds and sinuses. The poor outcome associated with fungal PJI relative to bacterial PJI should be shared with patients in order to manage the expectations of this complex cohort

Introduction and Objective. Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation. Materials and Methods. A retrospective study of adult patients in all UK hospitals, who underwent fibula nail fixation between 01/01/2018 and 31/10/2020 was performed. Primary outcome measures included time to union, infection rate, other post-operative complications associated with the fixation and length of hospital stay. The secondary outcome measure was to identify the indication for fibula nailing. Data tabulation was performed using Microsoft Excel and analysis was performed using SPSS Version 23 (SPSS Statistics). Results. 2 Major Trauma Centres (MTCs) and 9 Trauma Units (TUs) were eligible for inclusion. 102 patients were included and 91% were classified as ankle fractures of 68% (n=69) were Weber B, 24% (n=24) Weber C and 8% (n=9) were either distal tibial fractures with an associated fibula fracture or pilon fractures. The mean age was 64 years of which 45 were male patients and 57 were female. The average BMI was 30.03kg/m. 2. and 44% of patients were ASA 3. 74% of patients had poor pre-op skin condition including swelling and open wounds. The calculated infection rate for fibula nail was 4.9% and metal-work complication rate was 4.9%. The average time to union was 13 weeks and length of inpatient stay was 15 days (SD +/− 12 days). Conclusions. MEFNO has demonstrated that fibula nail is an ideal implant in patients who have a physiologically higher risk of surgery, poor skin condition and a complex fracture pattern. The time to union, complication and infection risks are lower than that reported in literature for ankle ORIFs

Aims. The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs. Methods. Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification. Results. Adjusted mean total NHS and PSS costs were £13,785 following treatment of complex fractures and £3,550 following treatment of simple fractures, where the open fracture wound is closed at the end of the first wound debridement, generating a mean difference of £10,235 (95% confidence interval £8,074 to £12,396). Conclusion. Following previous work correlating clinical outcomes with the OTS classification of open fractures, this study suggests that the new OTS classification also correlates with economic costs estimated from alternative study perspectives. Cite this article: Bone Joint J 2022;104-B(3):408–412

Aims. It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT. Methods. This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples t-test were applied for secondary outcomes. Analyses of primary and secondary outcomes were performed using SPSS v. 22.0.1 and p-values of < 0.05 were considered significant. Results. A total of 486 patients were randomized between January 2016 and December 2018. Overall 206 (49.04%) patients underwent NPWT, while 214 (50.95%) patients were allocated to the standard dressing group. There was no statistically significant difference in DRI at 12 months between NPWT and standard dressing groups (mean difference 0.5; 95% confidence interval (CI) -0.08 to 1.1; p = 0.581). Regarding SF-12 scores at 12 months follow-up, there was no significant difference at any point from injury until 12 months (mean difference 1.4; 95% CI 0.7 to 1.9; p = 0.781). The 30-day deep infection rate was slightly higher in the standard gauze dressing group. The non-union odds were also comparable (odds ratio (OR) 0.90, 95% CI 0.56 to 1.45; p = 0.685). Conclusion. Our study concludes that NPWT therapy does not confer benefit over standard dressing technique for open fractures. The DRI, SF-12 scores, wound infection, and nonunion rates were analogous in both study groups. We suggest surgeons continue to use cheaper and more readily available standard dressings. Cite this article: Bone Joint J 2020;102-B(7):912–917

Aims. Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Methods. Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Results. Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Conclusion. Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802–1808

Purpose: The choice of irrigating fluid and delivery pressure remains controversial. Identifying surgeons’ preferences in techniques and the rationale for their choices may aid in focusing educational activities to the orthopaedic community as well as planning future clinical trials. Our objective was to clarify current opinion with regard to the irrigation of open fracture wounds. Method: We mailed and delivered a cross-sectional survey using a sample-to-redundancy strategy to members of the Canadian Orthopaedic Association and attendees of an international fracture course (AO, Davos, Switzerland) to examine surgeons’ preferences in the initial management of open fracture wounds. Results: Of the 1,764 surgeons who received the questionnaire, 984 (55.8%) responded. In the management of open wounds, most surgeons surveyed, 676 (70.5%), favoured normal saline alone, however 16.8% used Bacitracin. Many surgeons, 695 (71%) used low pressures when delivering the irrigating solution to the wound, however variation exists in what constituted high versus low pressure lavage. Surgeons supported the need for a clinical trial evaluating outcomes following both the use of different irrigating solutions as well as irrigating pressures [803 (84.8%) and 730 (77.6%) respectively]. Conclusion: The majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds

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

Aim. Fracture-related infection (FRI) is an important complication following surgical fracture management. Key to successful treatment is an accurate diagnosis. To this end, microbiological identification remains the gold standard. Although a structured approach towards sampling specimens for microbiology seems logical, there is no consensus on a culture protocol for FRI. The aim of this study is to evaluate the effect of a structured microbiology sampling protocol for fracture-related infections compared to ad-hoc culture sampling. Method. We conducted a pre-/post-implementation cohort study that compared the effects of implementation of a structured FRI sampling protocol. The protocol included strict criteria for sampling and interpretation of tissue cultures for microbiology. All intraoperative samples from suspected or confirmed FRI were compared for culture results. Adherence to the protocol was described for the post-implementation cohort. Results. In total 101 patients were included, 49 pre-implementation and 52 post-implementation. From these patients 175 intraoperative culture sets were obtained, 96 and 79 pre- and post-implementation respectively. Cultures from the pre-implementation cohort showed significantly more antibiotic use during culture sampling (P = 0.002). The post-implementation cohort showed a tendency more positive culture sets (69% vs. 63%, P = 0.353), with a significant difference in open wounds (86% vs. 67%, P = 0.034). In all post-implementation culture sets causative pathogens were cultured more than once per set, in contrast to pre-implementation (P <0.001). Despite stricter tissue sampling and culture interpretation criteria, the number of polymicrobial infections was similar in both cohorts, approximately 29% of all culture sets and 44% of all positive culture sets. Significantly more polymicrobial cultures were found in early infections in the post-implementation cohort (P = 0.048). This indicates a better yield in the new protocol. Conclusions. A standardised protocol for intraoperative sampling for bacterial identification in FRI is superior than an ad-hoc approach. This was the combined effect of no antibiotics around sampling, more tissue samples with the ‘no touch-technique, increased awareness for both surgeon and microbiologist and stricter criteria for diagnosis. It resulted in more microbiologically confirmed infections and more certainty when identifying causative pathogens

We have conducted a case-control study over a period of ten years comparing both deep infection with methicillin-resistant staphylococcus aureus (MRSA) and colonised cases with a control group. Risk factors associated with deep infection were vascular diseases, chronic obstructive pulmonary disease, admission to a high-dependency or an intensive-care unit and open wounds. Those for colonisation were institutional care, vascular diseases and dementia. Older age was a risk factor for any MRSA infection. The length of hospital stay was dramatically increased by deep infection. These risk factors are useful in identifying higher-risk patients who may be more susceptible to MRSA infection. A strategy of early identification and isolation may help to control its spread in trauma units

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

1. In the first 1600 of the series of peripheral nerve injuries treated during the years 1940-45 at the Peripheral Nerve Injuries Unit, Oxford, 52 per cent. were due to penetrating wounds, and 6 per cent. of these involved the brachial plexus. 2. A specific method of grouping and grading recovery is described: Group I—lesions of the roots and trunk of C.5, 6; Group II—lesions of the posterior cord; Group III—lesions of C.8, T.1, and the medial cord. 3. The recovery of cases in Group I was good, in Group II fair, and in Group III poor. 4. The brachial plexus was explored on twenty-two occasions. Only in four instances was there interruption of continuity—which is in striking contrast with the frequency in more distal degenerative nerve lesions in open wounds. 5. There is no evidence to suggest that neurolysis influenced motor or sensory recovery, but on one occasion it relieved persistent pain in the limb. In general the correlation between operative findings and prognosis was not precise. 6. With one exception, no recovery of consequence took place in the small muscles of the hand after a lesion in continuity, although galvanic stimulation to all paralysed muscles had been given regularly. 7. There is evidence to suggest that innervation of the biceps may not always be limited to C.5 and 6 and that in a proportion of cases C.7 may make a substantial contribution. 8. In five cases (12 per cent.) Horner's syndrome was present; the causation is discussed. 9. In every case of damage to a main vessel there was a marked tendency to joint stiffness, particularly in the hand, but on one occasion only was there evidence of ischaemic changes in the muscles and nerves. 10. The good spontaneous recovery which occurred in Groups I and II; the poor recovery in Group III even in cases where there was an apparently favourable lesion in continuity; the rarity with which division of nerves was found at operation; and the discouraging results of repair in three cases; make it necessary to conclude that routine exploration of open wounds of the brachial plexus is neither profitable nor justifiable

Aim. Antibiotic prophylaxis is critical for the prevention of fracture related infection (FRI) in trauma patients, particularly those with open wounds. Administration of prophylactic antibiotics prior to arrival at the hospital (e.g. by paramedics) may reduce intraoperative bacterial load and has been recommended; however scientific evidence for pre-hospital administration is scarce. Methods. The contaminated rabbit humeral osteotomy model of Arens was modified to resemble the sequence of events in open fractures. In an initial surgery representing the “accident”, a 2mm mid-diaphyseal hole was created in the humerus and the wound was contaminated with a clinical Staphylococcus aureus strain (mean 1.6×106 Colony Forming Units, CFU). The animals were allowed recover for 4 hours mimicking the period from trauma to debridement. At this time, a second procedure was performed in order to debride and irrigate the wound, and to fix a complete osteotomy that was made through the initial defect. Three test groups were included (n=8 rabbits per group): 1) no antibiotic therapy; 2) standard “in-hospital” antibiotic prophylaxis (24 hours therapy starting 30 minutes before surgery); 3) “pre-hospital” antibiotics (single dose 15 minutes after the “accident”). The antibiotic used was cefuroxime and was administered in a weight-adjusted dosage. Results. In the absence of any antibiotic administration (group 1), high bacterial counts were identified at fixation (1.89×106 CFU) and at euthanasia (day 7, 7.70×107 CFU) in all rabbits. When 24 hours of antibiotics were administered commencing “in hospital” (group 2), the bacterial load during fixation surgery was slightly reduced (CFU 9.88×105) and 50% of animals were infected at euthanasia. When one single shot of antibiotics was administered in the “pre-hospital” setting (group 3), the bacterial load during fixation surgery was significantly lower than for both groups 1 and 2(CFU 2.34×103) yet all animals were infected at euthanasia. Conclusions. Early pre-hospital administration of antibiotics significantly reduced the bacterial load in the operative field at the time of debridement compared to regular prophylaxis. However, continuation of systemic antibiotics is necessary in order to prevent infection in this model

Introduction Management of bedsores in traumatic paraplegia has been a challenge since time immemorial. Conventional serial debridement and dressings require prolong hospitalization, imply posible complications and are an economic burden. Modalities like hyperbaricoxygen, electrical stimulation, altered cultured keratinocytes are cumbersome, expensive, and not readily available. Negative pressure to promote wound healing is under evolution. This study evaluates the effect of negative pressure in bedsore management. Methods The Negative Pressure Device (NPD) included sterilized foam, a low power continuous suction apparatus (Romovac) and a transparent polyurethane adhesive dressing. NPD was exclusively a bedside procedure. The perforated end of a drainage tube was placed on the wound surface and other end exited 10 cms away from wound margin, connected to Romovac. Sterilized foam was trimmed to size and geometry of wound as cover. Opsite closed the wound with an airtight seal. The bellow of Romovac was charged to attain negative pressure. Recharging was done after five to six hours. The wound inspected and dressings changed every five to seven days. Results NPD converted an open wound into a close controlled wound. By drawing away fluid from the wound it prevented collection of secretions and decreased purulence. Negative pressure increased vascularity, enhanced granulation tissue and rapidly reduced the size and depth of wound. Airtight sealing prevented soiling and odor enabling universal acceptance. In controlled based study, NPD: Reduced the frequency of dressing from once daily to once in five to seven days (cost effective). Reduced bacterial contamination and substantially increased granulation tissue. Serial microbial assessment of wound revealed efficacy in controlling bacterial growth and achieving a sterile culture within 10 days. Prooved itself to be an efficient and painless method of serial debridement. Reduced wound size and depth to one third of the original within three weeks. Was well tolerated by patients. The drawbacks of NPD were: Failure in low sacral bedsores close to the natal cleft. Difficulty in getting an airtight seal using Opsite. The tendency of the sterile foam to disintegrate, making the secretions viscous and clogging the drain. Tendency to increase bleeding, during changes of dressings, from the exuberant granulation tissue which formed. Conclusions NPD is a bedside procedure, easy to apply, with minimal side effects. It reduces the frequency of dressings and duration of hospitalization. By converting an open wound into a close-controlled wound it decreases purulence, hastens recovery and prevents soiling and the characteristic odor. The NPD apparatus suggested is innovative, cost-effective

Purpose: The optimal choice of irrigating solution or irrigating pressure in the initial management of open fracture wounds remains controversial. FLOW compared the effect of castile soap versus normal saline, and low versus high pressure pulsatile lavage on one year re-operation rates in patients with open fracture wounds. Method: We conducted a multicenter, blinded, two-by-two factorial, pilot randomized trial of 111 patients with open fracture wounds receiving either castile soap solution or normal saline and either high or low pressure pulsatile lavage. The primary outcome, reoperation within one year, included infections, wound healing problems, and nonunions. Secondary outcomes included all operative and non-operative infections, wound healing problems, nonunion and functional outcomes. We followed the intention to treat principle. Results: Eighty-nine patients (80.2%) completed the 12-month follow-up. As anticipated in this small-sample-size pilot study, results were compatible with substantial benefit and substantial harm: the hazard ratio (HR) for reoperation with castile soap was 0.77, 95% CI 0.35 to 1.69, p=0.52; with low pressure lavage, the hazard ratio for the risk of reoperation was 0.56, 95% CI 0.25 to 1.27, p=0.17. Secondary outcomes showed a significant relative risk reduction for nonunion of 63% in favour of castile soap (p=0.036), and a trend for a relative risk reduction for nonunion of 44% in favour of low pressure lavage (p=0.22). Conclusion: The FLOW pilot study suggests the possibility of an important reduction in reoperation rates for both castile soap and low pressure pulsatile lavage. Our findings provide compelling rationale for continued investigation in a pivotal FLOW trial of 2280 patients

The optimal choice of irrigating solution or irrigating pressure in the initial management of open fracture wounds remains controversial. FLOW compared the effect of castile soap versus normal saline, and low versus high pressure pulsatile lavage on one year re-operation rates in patients with open fracture wounds. We conducted a multicentre, blinded, two-by-two factorial, pilot randomised trial of 111 patients with open fracture wounds receiving either castile soap solution or normal saline and either high or low pressure pulsatile lavage. The primary outcome, re-operation within one year, included infections, wound healing problems, and nonunions. Secondary outcomes included all operative and non-operative infections, wound healing problems, nonunion and functional outcomes. We followed the intention to treat principle. Eighty-nine patients (80.2%) completed the 12-month follow-up. As anticipated in this small-sample-size pilot study, results were compatible with substantial benefit and substantial harm. The hazard ratio (HR) for re-operation with castile soap was 0.77 (95% Confidence Interval (CI) 0.35 to 1.69, p=0.52). With low pressure lavage, the hazard ratio for the risk of re-operation was 0.56, 95% CI 0.25 to 1.27, p=0.17. Secondary outcomes showed a significant relative risk reduction for nonunion of 63% in favour of castile soap (p=0.036), and a trend for a relative risk reduction for nonunion of 44% in favour of low pressure lavage (p=0.22). Functional outcome scores showed no significant differences at any time point between groups. The FLOW pilot randomised controlled trial demonstrated the possibility that the use of low pressure may decrease the re-operation rate for infection, wound healing problems, or nonunion. Our findings provide compelling rationale for continued investigation in a pivotal FLOW trial of 2280 patients

Hip fracture in the elderly is associated with significant morbidity and mortality. Significant intra-operative blood loss and the subsequent need for transfusion significantly contribute to patient morbidity. Making a surgical incision with diathermy reduces wound related blood loss, by coagulating small vessels as tissue is incised, however no study to date has looked at the use of diathermy in making surgical incisions around the hip. In addition, the increasing prevalence of blood borne infections makes the exclusion of sharps from the operative field an attractive option. The aim of this study was to compare diathermy incision with traditional wound opening using a scalpel to incise all layers. 50 patient undergoing hemiarthroplasty for fractured neck of femur were recruited prospectively. Patients on warfarin were excluded from the study while those on aspirin were not. After informed consent was obtained patients were randomized to scalpel or diathermy incision by coin toss. In the diathermy group the dermis was incised with the scalpel and all further layers with the diathermy, while in both groups diathermy as used for haemostasis. All patients received prophylactic antibiotics at induction and for 24 hours post-op. Wounds were closed in a standard fashion using absorbable sutures for closing fascia and fat layers and surgical staples for skin. Intra-operative parameters measured included: 1) Time to open wound – defined as time taken to open wound from skin incision to complete opening of the fascia lata and achieve haemostasis. 2) Wound length and depth. 3) Wound related blood loss – swabs used while creating and closing the wound were weighed separately. 4) Total operative blood loss. Post-operatively all wound related complications were recorded. Statistical analysis was performed using the un-paired Student t-test parametric data. Both groups were similar in relation to age, sex and pre-operative aspirin use. Intra-operatively neither wound sizes nor time taken to create the wound were statistically significantly different. In the scalpel group wound related blood loss represented over 30% of the total operative blood loss as compared with only 18.5% in the diathermy group. Post-operatively there were no wound infections or dehiscences in either group, however 4 patients in the scalpel group developed significant wound ooze that responded to conservative treatment. There were no significant wound problems in the diathermy incision group. This prospective study has shown that the use of diathermy incision for hip hemiarthroplasty significantly reduces wound related blood loss and the incidence of post-operative wound ooze. We conclude that the routine use of diathermy to make incisions around the hip is effective in reducing wound related bleeding without adverse effects on wound healing or infection rate

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

Aims

To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes

Negative pressure wound therapy (NPWT) is commonly used to manage severe open fracture wounds. The recently completed X randomized controlled trial (RCT) evaluated the effect of NPWT versus standard wound management on 12-month disability and rate of deep infection among patients with severe open fractures of the lower limb and reported no differences. Using data from the Y trial of open fracture patients, we aimed to evaluate the impact of NPWT on the odds of having deep infections and health-related quality of life (HRQL). Our analyses included participants from the Y trial who had Gustilo II and III lower extremity fractures. To adjust for the influence of injury characteristics on type of dressing received, a propensity score was developed from the dataset. A one-to-one matching algorithm was then used to pair patients with a similar propensity for NPWT. Mixed effects logistic regression was used to evaluate the association between type of wound dressing and development of a deep infection requiring operative management (dependent variable) in the matched cohort. Gustilo type, irrigation solution, fracture location, mechanism of injury, and degree of contamination were included as adjustment variables. To determine any differences in HRQL between the NPWT and standard wound dressing groups, we conducted two multi-level models with three levels (centre, patient, and time) and included Short Form-12 (SF-12) Physical Health Component (PCS) and SF-12 Mental Health Component (MCS) as dependent variables. Gustilo type, irrigation solution, fracture location, mechanism of injury, degree of contamination, and pre-injury SF-12 scores were included as adjustment variables. All tests were 2-tailed with alpha=0.05. After applying propensity score-matching to adjust for the influence of injury characteristics on type of dressing used, there were 270 matched pairs of patients available for comparison. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.22 times higher in patients who received NPWT compared to those who did not receive NPWT (Odds Ratio (OR) 4.22, 95% Confidence Interval (CI) 2.26–7.87. 1,329 participants were included in our HRQL analysis and those treated with NPWT had significantly lower SF-12 PCS at all follow-up visits (6w, 3m, 6m, 12m) post fracture (p=0.01). Participants treated with NPWT had significantly lower SF-12 MCS at 6-weeks post-fracture (p=0.03). Unlike the X trial, our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management and that being treated with NPWT was associated with lower physical quality of life in the 12 months post-fracture. While there may have been other potential adjustment variables not controlled for in this analysis, our results suggest that the use of this treatment should be re-evaluated

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.

Aims

Fungal periprosthetic joint infections (PJIs) are rare, but their diagnosis and treatment are highly challenging. The purpose of this study was to investigate the clinical outcomes of patients with fungal PJIs treated with two-stage exchange knee arthroplasty combined with prolonged antifungal therapy.

Aims

The aim of this study was to determine the rate of indocyanine green (ICG) staining of bone and soft-tissue tumours, as well as the stability and accuracy of ICG fluorescence imaging in detecting tumour residuals during surgery for bone and soft-tissue tumours.

The February 2024 Foot & Ankle Roundup³⁶⁰ looks at: Survival of revision ankle arthroplasty; Tibiotalocalcaneal nail for the management of open ankle fractures in the elderly patient; Accuracy of a patient-specific total ankle arthroplasty instrumentation; Fusion after failed primary ankle arthroplasty: can it work?; Treatment options for osteochondral lesions of the talus; Managing hair tourniquet syndrome of toe: a rare emergency; Ultrasound-guided collagenase therapy for recurrent plantar fibromatosis: a promising line of therapy?.

Aims

Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment.

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

Infection and re-fracture are well-described complications following open paediatric forearm fractures. The purpose of this paper is to determine if patient, injury, and treatment characteristics can be used to predict the occurrence of these complications following the surgical management of paediatric open forearm fractures. This is an IRB-approved retrospective review at a single-institution paediatric level 1 trauma centrefrom 2007–2013 of all open forearm fractures. Medical records were reviewed to determine the type of open fracture, time to administration of initial antibiotics, time from injury to surgery, type of fixation, length of immobilisation, and complications. Radiographs were studied to document fracture characteristics. 262 patients with an average age of 9.7 years were reviewed. There were 219 Gustillo-Anderson Type 1 open fractures, 39 Type 2 fractures, and 4 Type 3 fractures. There were 9 infections (3.4%) and 6 re-fractures (2.3%). Twenty-eight (10.7%) patients returned to the operating room for additional treatment; 21 of which were for removal of implants. Contaminated wounds, as documented within the medical record, had a greater chance of infection (21% vs 2.2%, p=0.002). No difference in infection rate was seen with regard to timing of antibiotics (p=0.87), timing to formal debridement (p=0.20), Type 1 versus Type 2 or 3 open fractures (3.4% vs 5.0%, p=0.64), 24 hours vs. 48 hours of post-operative IV antibiotics (5.2% vs 3.5%, p=0.53), or when comparing diaphyseal, distal, and Monteggia fracture patterns (3.6 vs 2.9% vs 5.9%, p=0.81). There was no difference in infection rate when comparing buried or exposed intramedullary implants (3.5% vs 4.2%, p>0.99). Rate of re-fracture was not increased based on type of open wound (p>0.99) or fracture type (0.4973), although 5 of the 6 re-fractures were in diaphyseal injuries. In this series of open paediatric both bone forearm fractures, initial wound contamination was a significant risk factor for subsequent infection. The rate of infection did not vary with timing of antibiotics or surgery, type of open fracture, or length of post-operative antibiotics. A trend to higher re-fracture rates in diaphyseal injuries was noted. Surgeons should consider planned repeat irrigation and debridement for open forearm fractures with obviously contaminated wounds to reduce the subsequent infection risk

Background:. Severe kyphosis in myelomeningocoele patients results in seating problems, early satiety and ultimately pressure sores over the prominence. Kyphectomy and sagittal correction can improve these morbidities. Aim:. To evaluate the outcome of kyphectomy surgery in meningomyelocoele children. Methods:. A retrospective review was performed of a single surgeon series of paediatric myelomeningocele patients who underwent kyphectomy surgery. All the patients had posterior fusion, employing pedicle screws and sub laminar wiring. All the posterior fusions extended to the pelvis either to include S1 or the ilium. Prior to surgery, three children had open wounds over the apex of the deformity. Despite prone nursing, these failed to heal. These were closed primarily intra-operatively without the requirement of flaps. Results:. Seven children (four males, three females) were identified with an average age of 9.5 (8–13) years. The kyphosis was corrected from a mean range of 110° (88°–180°) to post-operative range of 5°–45°. The operative time averaged 240 min (165–284 min) with an estimated blood loss average of 957 ml (500–2550 ml). All the patients recovered well and no short-term complications were experienced except one transient CSF leak intra operatively. Two patients presented with sub-acute delayed infection requiring removal of instrumentation once the spine had fused. There was one case of instrumentation failure. All patients had improved wheel chair seating. Conclusion:. Kyphectomy in myelomeningocele is an infrequently required procedure which is effective in sagittal correction and improved seating with an acceptable complication rate

Aims

The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system.

Infection is a potentially disastrous complication of total knee arthroplasty (TKA). Although advances in surgical technique and antibiotic prophylaxis have reduced the incidence of infection to approximately 1% in primary TKA, there is still a substantial number of patients. Treatment options include antibiotic suppression, irrigation and debridement with component retention (with or without polyethylene exchange), one-stage or two-stage revision, resection arthroplasty and rarely arthrodesis or amputation. Salvage of prostheses has always been associated with low rates of success. It was reported a success rate of 27% for open debridement. It is suitable for selective cases where infection occurs within the first 4–6 weeks of primary TKA or in the setting of acute hematogenous gram positive infection with stable implants. With the advances in arthroscopic technique, arthroscopy after TKA has become an accepted method to assess and manage the complications of TKA. Arthroscopic treatment for infected TKA was reported and the successful rate was similar or better than open debridement in selected situations. We used arthroscopic debridement combined with continuous antibiotic irrigation and suction to treat acute presentation of infected TKA with acceptable result. From 2010∼2013, we has performed arthroscopic debridement and continuous antibiotic irrigation system for seven patients with infected TKA. All of the seven patients had no open wounds nor sinuses and no radiological evidence of prosthetic instability or evidence of osteomyelitis. Most of the surgical intervention was performed within two weeks from the onset of symptoms. Arthroscopic debridement was performed with a shaver using a multiportal technique (anterolateral, anteromedial, superolateral, superomedial, posterolateral, posteromedial) and a continuous antibiotic irrigation system was used to dilutes concentration of the causative microorganism and keep high local bactericidal concentration of antibiotics. We evaluated the efficacy by using follow up of the C-reactve protein (CRP) test, erythrocyte sedimentation rate (ESR) test and physical examination. Successful treatment was defined as prosthesis retention without recurrent infection by the final follow-up. Six of seven infected TKA were cured without recurrence at a mean follow-up of 23 months (range, 6–41 months). One case with rheumatoid arthritis under long-term steroid therapy had recurred after episode of upper respiratory tract infection for 3 times. However, the infection was controlled by arthroscopic debridement and retention of the prosthesis was achieved. We emphasize the importance of posterior portal to ensure adequate arthroscopic debridement. It is imperative to make early diagnosis and treatment for infected TKA. We should make more effort to preserve the prosthesis in acute infection(within 2 weeks). With the advantage of minimal morbidity, arthroscopic treatement shoulder be an alternative to open debridement

There have been a worldwide change in the susceptibility patterns of antibiotics by many community-acquired microorganisms including those associated to wound infection after open fractures. However, the current antibiotic prophylaxis practice adopted by orthopedic surgeons to prevent infectious complications following open fractures has not changed, since Gustilo and Andersen classification was published several decades ago. Few studies have addressed the current pattern of infectious organisms identified in open fracture wounds and its susceptibility to antibiotics that have been empirically used. We aim to study the incidence of community-acquired resistant organisms isolated in lower extremities open fracture and analyze if antibiotic therapy based upon identified resistant pathogens, would decrease surgical site infection (SSI) rates. In a prospective, single center cohort study, from August 2013 to March 2015 at a tertiary public university institution, 136 subjects presenting Gustilo type II or III lower extremities open fractures were randomly assigned in two arms. Both arms were submitted to surgical debridement, fracture stabilization, and empirical antibiotic therapy, but subjects on Group II had at least three samples of tissue cultures collected during debridement. Patients previously treated at an emergency department other them ours were excluded. When resistant bacteria was identified, antibiotic therapy was modified according to antibiogram tests. The primary outcome was to compare the infection rates between these two groups, after early 60-days follow up. We included 136 patients with Gustilo-II (43.4%), –III, (34.5%) open fractures, of which 86% were male, with median age of 33.7 years, and 69.1% presented no comorbidities. Group II (collection of tissue cultures) accounted 36.7% of patients, and among them bacterial growth were detected in 36% (16/50). Microorganism resistant to empirical antibiotic therapy was identified in 18% (9/50), including Staphylococcus aureus, coagulase-negative Staphylococci, Enterococcus sp, Pseudomonas aeruginosa, Klebsiella sp, Serratia sp, Escherichia coli, and Enterobacter sp. Median duration of antibiotic treatment was eleven days. During 60-days of follow up, 71 patients (52.2%) were evaluated for signs of infection using the Centers for Disease Control and Prevention criteria, of which 63.4% (45/71) and 36.6% (26/71) were on Group I and II, respectively. No significant difference in the rates of SSI was observed between the study arms (19.2% vs 22.2%, respectively, P = 0.95). We detected higher rates of bacterial resistance on Gustilo type II and III open fracture wounds, but adjusting antibiotic therapy towards these contaminants did not affected the rates of infection afterwards

Aims

This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma.

Aims

In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

We examined the recovery of power in the muscles of the lower limb after fracture of the tibial diaphysis, using a Biodex dynamometer. Recovery in all muscle groups was rapid for 15 to 20 weeks following fracture after which it slowed. Two weeks after fracture the knee flexors and extensors have about 40% of normal power, which rises to 75% to 85% after one year. The dorsiflexors and plantar flexors of the ankle and the invertors and evertors of the subtalar joint are much weaker two weeks after injury, but at one year their mean power is more than that of the knee flexors and extensors. Our findings showed that age, the mode of injury, fracture morphology, the presence of an open wound and the Tscherne grade of closed fractures correlated with muscle power. It is age, however, which mainly determines muscle recovery after fracture of the tibial diaphysis

Purpose of the study: Bipolar dislocation of the first metatarsal, also called floating metatarsal, remains a rare traumatic injury of the first ray of the foot. This is an acute unstable post-traumatic metatarsophalangeal and cuneometatarsal injury occurring simultaneously or successively. Most earlier reports have been single case reports. We report here three successive cases in adults to study the mechanism of the injury, the clinical forms and the different therapeutic modalities. Material and method: The patients were three males aged 35 years on average who presented a bipolar dislocation of the first metatarsal. Results: The causal event was an automobile accident for two patients and a work accident for one. There was an open wound in two cases over the metatarsophalangeal joint. Orthopaedic metatarsophalangeal reduction was achieved in two cases and open cuneometarsal reduction in one. The cuneometatarsal reduction was maintained with a pin for six weeks. The auto-reduction was then continued. Discussion: Described for the first time by English as a paired dislocation, in 1997 Liebner coined the term of a floating metatarsal. We were able to identify eight publications in the literature. The causal mechanism would be successive dislocation of themetatarsophalangeal joint first followed by the cuneometatarsal joint. The metatarsophalangeal dislocation was dorsal in two patients and lateral in one. The sesamoid girdle remained intact (Jahns 1) and in all cases followed the first phalanx in its displacement (Garcia Mata S+). The cuneometatarsal dislocation was dorsal in all cases. The skin opening involved the plantar surface in one case and was medial in the other, allowing externalisation of the first metatarsal head. The floating metatarsal was isolated in one case and associated with a fracture of the second metatarsal in two. Primary reduction of the metatarsophalangeal joint then the cuneometatarsal joint was achieved in all cases. Irreducibility due to a button effect was noted in one case. At minimum three months follow-up, there has been no evidence of deformity. The foot has remained pain free with correct shoe wearing. The control x-rays have not shown any subluxation. Conclusion: The floating first metatarsal is an exceptional foot injury. Primary reduction of the metatarsophalangeal joint appears to be the rule. Adequate primary treatment ensures satisfactory outcome

Introduction: A Bradford sling is a device with which the arm can be held in an elevated position in the trauma or post-op elective setting to reduce swelling. It is marketed as a single use item but in many orthopaedic departments it is used multiple times before being discarded especially in the elective recovery setting. We asked the question ‘are there any microbiological implications to the re-use of Bradford slings?’ In our department Bradford slings were used in recovery for patients who had undergone hand surgery as a day-case. The sling would then cease to be used once it had become mechanically unusable. Method: The Bradford slings employed in a one-month period by a single consultant working in the day surgery unit of the study hospital were examined. Prior to and following each use agar plates were inoculated by pressing the sling directly onto the plates. Two areas each of 5cm. 2. , one in the arm and one in the forearm section of the slings were defined and labeled proximal and distal. Aseptic technique was used to avoid contamination by the investigator but otherwise the slings were treated in the same fashion as usually they would be. Patients were all screened for MRSA and were all negative. Results: In a one-month period 6 slings were used between 2 and 7 times (mean 4) resulting in 96 inoculation events. 89 (92.7%) of these events yielded significant bacterial growth. Most of these colonies were coagulase-negative Staphylococcus or Bacillus, however coliforms were cultured 5 (5.2%) times and Staphylococcus Aureus twice (2%). Also all slings demonstrated bacterial growth immediately after removal of packaging prior to first use. Indeed one sling grew coliforms prior to its first use. There were no incidences of wound infection at 6-week follow-up. Conclusion: The re-use of the Bradford sling poses no threat to the elective post-op patient. Most of the organisms isolated were environmental organisms unlikely to cause infection. There would only be a significant risk of infection if a patient had an open wound. Interestingly none of the Bradford slings were sterile prior to use. This study demonstrates that there appears to be minimal risk to the patient in re-using slings, but the numbers in this study are limited and a larger study would be helpful in assessing the risk further

Objective: 57 open tibia fractures treated with external fixation during the period 1996–2001 are presented. Material and Methods: 57 open tibia fractures concerning 52 patients (45 males, 12 females) were treated with external fixation during the period 1996–2001. Fracture classification according Gustilo included 5 type I fractures, 14 type II fractures, 18 type IIIA fractures and 20 type IIIB fractures. The following external fixation devices were used: STAR in 3 patients, EXFIRE in 9 patients, HOFFMANN in 18 patients, ORTHOFIX in 27 patients. All open wounds were left to heal at secondary intention. The devices were fully functional within 4 to 8 weeks in 37 patients depending on the type of the fracture. Results: 39 fractures were completely healed in a mean time of 16 weeks. Nine fractures had delayed union and finally were completely healed without using alternate devices. In 8 cases there was pseudarthrosis; internal fixation with intramedullary nail was used in seven of these cases, and 2 cases were treated with grafts. One case was complicated with septic pseudarthrosis that was treated by bone transfer in a tertiary centre. Wound healing was achieved in 45 cases. Delayed skin surgical closure was needed in 12 cases. Needle infection rate was 27%, while in 4 cases there was deep infection and needles were removed. Conclusion: For the vast majority of open tibia fractures, external fixation can be used as a permanent way of treatment. Clinicians should set external fixation with this permanent prospective

Restoration of the bone defects on the background of the purulent osteomyelitis process is one of most pressing problems in orthopedics. In the last few years the medical procedure was improved thanks to use of semi-synthetic or syntetic implantation biodegradable composite materials. The object of the investigation is to study possibilities of use of fast-biodegradable implant LitAr (Russia) for filling infected bone defects in course of complex treating various osteomyelites forms. The composite material LitAr (in plates) is a mixture of components: xenocollagen and hydroxoapatite. Material is intended for stimulating osteogenesis. In event of infection materials LitAr in 7-10 days is lysed by the wound and microbe ferments and cannot support purulent process. Composite material was introduced into osteomyelitis defect intraoperative through an open wound by introducing a dry substance through fistu-las as well as in form of a suspension in 0.9%-sodium chloride solution. For 13.6% of patients postoperative time period was complicated by suppuration of operative wound. It was stated in course of use of material LitAr that in spite of secondary wound suppuration active osteogenesis rate was little different from similar process for patients with wound healing by first intention. It made it possible to use material more active for patients of advanced years because it was impossible to use a radical sanitation of purulent bone cavity for these patients. Material LitAr was used for 13 patients with osteomyelitis cavities. In form of a suspension (injection-ally or through a fistular duct) in 0.9% NaCl solution material was introduced through fistulas for 8 patients with an affected shin bone. Roentgenological signs of consolidation emerged by 35-40 days. A complete ossi-fication set in by 95-120 days. Immobilization was performed by use of plaster. In far-off time periods (about 2 years) no pathologic fractures were noted. 2 patients had a relapse of fistulas formation (15.4%). The use of implant LitAr for filling infected bone defects for stimulating osteogenesis and for restoring bone continuity in a complex treatment of various forms of osteomyelitis can be considered as an effective one including for patients because it was impossible to perform a radical sequestrectomy for these patients

Reports of infection by Clostridium sordellii associated with allograft transplantation have generated considerable interest. We report our experience in recognising clostridial contamination in cadaver donors of musculoskeletal tissue. Tissues obtained from 795 consecutive donors were excised using standard surgical techniques. Samples of blood and bone marrow were also obtained. Donors with clostridia recovered from any site were matched with the preceding donor without clostridia as a procedural and environmental control. The histories of the donors were analysed to determine which variables had a relationship to contamination by running a contingency table and chi-squared test on the variables against the event of a donor being contaminated. Sixty-four donors (8.1%) had clostridia, most commonly C. sordellii. Clostridia were grown from the blood, marrow and tissue samples of 52, 37 and 30 donors, respectively. In eight cases, they were cultured from the tissue samples alone. There was no significant difference in age or gender between the contaminated donors and the control group. Open wounds were more common in control than in contaminated subjects, but only death by drowning in the contaminated group was statistically significant (p = 0.02). The time between death and the excision of tissue which was contaminated (16 hrs 10 mins) compared with control (11 hrs 10 mins) donors was also significant (p < 10. −6. ). We conclude that there is clostridial contamination in a significant number of tissue donors, particularly with increasing time between death and tissue excision. Among the most commonly encountered species is C. sordellii. Multiple microbiological cultures, including blood, are necessary in order to identify clostridial contamination

Aims

To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury.

Aims

High-energy injuries can result in multiple complications, the most prevalent being infection. Vancomycin powder has been used with increasing frequency in orthopaedic trauma given its success in reducing infection following spine surgery. Additionally, large, traumatic injuries require wound coverage and management by dressings such as negative pressure wound therapy (NPWT). NPWT has been shown to decrease the ability of antibiotic cement beads to reduce infection, but its effect on antibiotic powder is not known. The goal of this study was to determine if NPWT reduces the efficacy of topically applied antibiotic powder.

Aims

The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

Introduction: Some centres in the UK have recently seen a shift away from internal fixation and free tissue transfer (Fix and Flap), towards temporary monolateral external fixation, soft tissue coverage and definitive Ilizarov frame fixation (Flap and Frame). Methods: Patients sustaining open fractures were identified prospectively and followed up beyond frame removal. After open wound debridement a monolateral ex-fix was applied. Soft tissue coverage was then achieved by our plastic surgeons. As the soft tissues settled, the temporary ex-fix was exchanged to an Ilizarov frame for definitive fixation. Open fractures with bone loss were similarly treated, with either acute shortening or bone transport, depending on the extent of bone loss and state of soft tissues. Results: Between July 2002 and June 2004, 21 grade 3 open fractures in 18 patients were treated by Flap and Frame. There were 15 male and 3 female patients, with mean age 36. Segment involved was 19 tibias and 2 femurs. There was associated bone loss (mean 9cm) in 6 fractures. 8 had other associated injuries. Gustilo grade, 3A/3B/3C = 6/13/2. Both 3C fractures required early amputation. Wound closure, 5/6 fractures with bone loss required free tissue transfer (FTT); however only 3/15 fractures without bone loss required FTT to achieve soft tissue cover, most requiring fasciocutaneous flap or split skin graft only. Median time in Ilizarov frame was 160 days for patients without bone loss. For those fractures with bone loss frame time ranged from 180–540 days, with some patients still requiring ongoing Ilizarov treatment. All fractures without bone loss united. At mean 14 month follow up only one fracture of 21 had clinical evidence of deep sepsis. 1 tibial fracture showed a 12 degree malunion, while 7/18 patients had a superficial pinsite infection requiring a course of oral antibiotics. One free tissue transfer failed in a grade 3C fracture, leading to early amputation (in conjunction with the recognised vascular injury). Conclusions: Grade 3 open fractures remain a significant treatment challenge. This was particularly true of those with associated bone loss, where without exception the treatment time in an Ilizarov frame was prolonged. A deep sepsis rate of 1/21 fractures treated by Flap and Frame compares favourably with other published series. In the 15 fractures without bone loss, times to union also compared very favourably. Unlike in previous series, many fractures did not require free tissue transfer, as there was no internal fixation device present at the fracture site requiring coverage. Flap and Frame appears to be a very satisfactory method of treating grade 3 open fractures, with low deep sepsis rate, high union rate, satisfactory times to union, and reduced requirement for free tissue transfer to obtain soft tissue coverage

Implant-associated infections do not spontaneously cure. The reason for persistence in device-associated infections is the biofilm, a specialized form of bacterial growth on surfaces. The biofilm represents a survival form of bacteria which is highly resistant against most antibiotics, and can persist over months or years as low-grade infection. Bacteria in biofilms enter a metabolically inactive state, embedded in an amorphous substance, called biofilm matrix. Together they form a complex three-dimensional structure with rudimentary communication and circulation systems. As a rule, only a combined surgical and antimicrobial management can eradicate biofilms and cure implant-associated infection. In selected patients, implant infections can be cured without implant removal with early debridement and long-term antibiotic treatment acting against biofilms. In this presentation, common pitfalls and reasons for treatment failure will be outlined and discussed. Adequate diagnosis. Every prosthesis with early loosening (< 2 years after implantation) or persistent/increasing pain should rise the suspicion of an implant-associated infection, which may presents without systemic signs of infection (fever), and can manifest without increased leukocyte counts or C-reactive protein). In this case, periimplant infection must be actively searched. Preoperative diagnosis includes aspiration of the synovial fluid of larger joints for Gram stain and culture; cell count and differential; and crystals (if appropriate). Swabs of the sinus tract (fistula) should not be performed, since they may not represent the causing organisms of the bone- or implant-associated infection. Intraoperative diagnosis includes multiple tissue biopsies around the prosthesis (no swabs), histopathology of the periprosthetic tissue and sonication of the removed device or its parts (if the method is available). For low-virulent organisms (such as Staphylococcus epidermidis or Propionibacterium acnes) at least two positive specimens with the same organism or an additional criterion for infection (i.e. acute inflammation in the tissue histopathology, presence of intraoperative pus or fistula) is needed. For slow-growing organisms, long incubation is needed (14 days) in order to culture these slow-growing and fastidious pathogens. Antibiotics should be discontinued at least 2 weeks prior to culture sample in order to minimize false-negative results. Novel diagnostic tests include PCR, which can also detect non-growing microorganisms and can be used for tissue specimens, joint aspirate or sonication fluid. Adequate antibiotic therapy. The identification of the infecting pathogen is paramount for a successful treatment. Therefore, no empiric antibiotic therapy should be administered before diagnosis is microbiologically confirmed. Antibiotics administered for a secreting wound overlying an implant is a critical mistake, which makes the etiological diagnosis difficult. In addition, the risk of development of antimicrobial resistance is high, particularly for rifampin. Therefore, rifampin should not be administered as long as there is a contact between body surface and implant (e.g. open wound or wound dehiscence, fistula, VAC foam, drainage). In contrast, addition of rifampin is absolutely necessary for eradication of staphylococcal infections of implants in case of retention (see presentation from W. Zimmerli S02.KL1). Other common mistakes are short duration of antibiotic treatment (totally 3 months are needed for eradication of biofilm), low antibiotic dose (high dosing is needed to achieve sufficient concentration in bone) or switch from intravenous to oral antibiotics with insufficient bioavailability (such as oral betalactams) or inactivity against biofilms (such as cephalosporins, macrolides or clindamycin). Adequate surgical therapy. Immediate debridement is indicated, if there is a suspicion of implant-associated infection (wound dehiscence, persisting secretion, lack of postoperative decrease of CRP). A revision is needed for diagnostic (adequate microbiological diagnosis) and therapeutic purposes (mechanical reduction of bacteria). The implant can be retained, if the symptoms of infection are lasting < 3 weeks, the prosthesis is stable and the infecting pathogen is susceptible to anti-biofilm antibiotics (i.e. staphylococci susceptible to rifampin). Importantly, a loose prosthesis can not be salvaged and always needs to be exchanged. Antimicrobial suppression therapy has a low probability of success (failure rate approximately 80% after 2 years). The drainages should be kept in place as short as possible, i.e. in general not more than 3 days. Large soft tissue defects require coverage with a flap. In conclusion, using the proposed diagnostic and treatment algorithm (. Zimmerli et al. . NEJM. 2004. ; . 351. : . 1645. ), the long-term success rate of periprosthetic joint infection is 80–90%. To avoid failure, it is important to select the patient for the least invasive, but still appropriate surgical and antibiotic treatment regimen and to avoid mistakes

Aims

To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes.

Aims

In wound irrigation, 1 mM ethylenediaminetetraacetic acid (EDTA) is more efficacious than normal saline (NS) in removing bacteria from a contaminated wound. However, the optimal EDTA concentration remains unknown for different animal wound models.

Despite of improved operative technique, ultra-clean air in the operating theater and systemically administered as well as in bone cement loaded antibiotics, septic complications after replacement arthroplasty of the knee still exist. Depending of the follow-up time in different reported series insidence vary from 0.5 to 5 per cent. Classic clinical symptoms, painful, swollen knee joint, possibly fever, indicate to more accurate examinations. Lesson to learn: . No treatment before adequate diagnosis !. No “homeostatic” antibiotics before accurate examinations. If the very first contact with physician or surgeon happens in such conditions, that adequate diagnostic methods are not available, patient has to be referred to hospital or institution with capable facilities. Prosthetic infection can be classified in many ways. The following classification is useful for the treatment purposes. Classification of infection:. 1. Early postoperative infection less than 4 weeks after surgery. superficial. deep. extensive soft tissue defects due to skin necrosis. 2. Originally patient is operated for aseptic loosening, but intraoperative cultures are positive. 3. Late chronic infection. 4. Acute hematogenous infection. Diagnostic methods:. 1. Clinical examination:. - symptoms can be suppressed by painkillers or immunomodulant drugs. - wound healing problems. - sinuses. - swelling, redness. - pain. - temperature increased. 2. Blood chemistry:. ESR, C-reactive protein and blood white cell count/ differentiation are helpful. Be ware if the patient has such a general disease, which increases fex CRP. 3. Routine x-rays. In early cases no significant signs, in late cases might appear erosions or cysts. 4. Isotope scintigraphy. Technetium- or indium labeled leucosytes are given intravenously. The patient is scanned 24 hours. Extended scintigraphy seems to be more sensitive than routine 6 to 8 hours‘ scintigraphy. 5. Joint aspiration. One has to sure, that the patient is not on antibiotics. If she/he is, antibiotics has to be stopped for two to four weeks, and aspiration performed after that, unless infection is not clinically obvious or situation is not life-threatening. White cell count/differentiation can be for some help. When the cell count is less than 2000/ml, and majority of cells are mononuclear, the result is indicative negative for infection. White cell count over 10000/ml, and majority polymorphonuclear, speaks for infection. When the aspiration has been carried in aseptic condition, positive culture is strong evidence for infection. Adequate handling of sample is important: as little as possible air in the syringe and as short as possible time used for transportation to lab. Treatment protocols. Treatment protocols can rather straight forward: if any sample culture is positive,. Two-stage revision arthroplasty is carried out. But also more conservative opinions are reported. 1.a. Early postoperative, superficial infection:. Surgical débridement of the wound. Careful examination of retinaculum layer. Lavage and wound closure if possible. Systemic antibiotics. Joint puncture and aspiration through healthy skin area, never through open wound. b. Early postoperative, deep infection:. Open débridement and careful lavage with retention of prosthesis. Additional peroperative samples for culture in order to confirm earlier pathogene definition. Systemic antibiotics regarding sensitivity estimation. Arthroscopic debridement and lavage has not proved to be better or neither as good as open. New aspiration 4–6 days after. If white cell count clearly over 10000/ml and possibly culture positive, new debridement and lavage. If third debridement comes necessary, even without bony changes, removal of prosthesis and antibiotics- loaded spacer has to be considered. c. Dehiscense of wound or soft tissue defect due to the necrosis:. Wound débridenent, antibiotics and depending on the extend of defect either partial closure, skin grafting or pedicled gastrocnemius muscle flap is performed. 2. In some cases there is no signs of infection, and the is operated as an aseptic loosening. In all revision, routineously 4 to 5 tissue samples should be taken for culture. If preoperatively there is any doubts about infection, histological examination of frozen sections should be carried out. If there are high count of polymorphonuclear cells, results of culture has to be waited. If later on in minimum two samples same pathogen is growing, the case has to be considered as infected. Two-stage revision protocol is recommended. One positive sample cannot be regarded as a concluding proof. Long term antibiotics is recommended. 3. Late chronic infection has insidious , slowly progressing onset. Symptoms can be confusing mild, and can lead to misdiagnosis. Method of choice is débridement, removal of the prosthesis and all bone cement, and placement of an antibiotics-loaded cement spacer. No dead space is left , but has to be filled with antibiotic-loaded collagen or antibiotic-cement beads. The patient is put on systemic antibiotics, preferably combination of two. Antibiotic therapy is continued six- to eight weeks. Healing process is controlled with ESR and CRP tests. If the blood test normal and clinical situation is normal, delayed revision arthroplasty is performed. Antibiotic loaded-cement is always used. 4. Acute hematogenous infection. Onset is usually acute and symptoms dramatic. Sometimes distant focus can be found. If the history is rather short( less than 14 days) open débridement, retainment of prosthesis, antibiotics-loaded collagen filling of the joint as well systemic antibiotics is recommended. Recovering is monitored by blood chemistry and repeated joint aspiration and cultures. If in aspiration sample there is high polymorphonueclear count and culture possibly positive, new débridemand is carried out. If signs of infection still continue, two-stage exchange to be considered. Pathogenes. Gram-positive. staphylococci are most frequent patogene in total knee replacement infections (95%). Gram-negative. bacilli cover the rest (5%). Coagulase-negative staphylococci has grown up the most important bacteria, and it‘s resistance against antibiotics has turned frightening. Spacers. In cases with short history retainment of prosthesis can be considered. Many authors change of polyethylene bearing. In two-stage revisions static antibiotic-loaded cement spacer was used during. The six to eight weeks‘ interval. Static spacer is connected with extensive bone loss as well as stiff causing problems in secondary revision. Molded cement spacer is used in order to avoid complications and to achieve better functional results. Failure. In some cases treatment of infection is unsuccessful. Arthodesis with method of Ilizarov or intramedullary nail or sometimes above-knee amputation comes necessary

Aims

Few risk factors for rotator cuff disease (RCD) and corresponding treatment have been firmly established. The aim of this study was to evaluate the relationship between numerous risk factors and the incidence of surgery for RCD in a large cohort.

Aims

Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation.

Aims

The purpose of this study was to determine whether intracellular Staphylococcus aureus is associated with recurrent infection in a rat model of open fracture.

Aims

The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb.

Topical treatment of infected wounds has a crucial role as an adjuvant to surgical debridement. Solutions currently used for local would treatment have either low antiseptic properties with low irritating effect, such as physiologically balanced solutions acting mostly by a mechanical irrigating effect, or antiseptic solutions which cause chemical irritation of the surrounding tissues. The use of topical substance with effective antiseptic properties, which is also not irritating to surrounding healthy tissues, should improve significantly the effectiveness of infected wound treatment. Previous reports on the use of Hexamethylenebiguanide solution for local antiseptic treatment in infected wounds indicated on a good curative effect without any local or systemic side effects. Unfortunately none of these reports is based on well designed statistical data which is essential for the safe and skilled use of any pharmaceutical agent. We present the results of controlled prospective double-blind study comparing the topical use of 0.1% Hexamethylenbiguanide solution with non lactated Ringer solution as agents for a topical treatment of infected wounds in extremities. The group of 104 patients with ischemic, combat, post surgical or due to open fracture wounds treated by either of these solutions following surgical debridement without additional systemic antibiotic use. According to the strict follow-up protocol, wounds’ healing was evaluated on a weekly basis. In the group of patients treated by the 0.1% Hexamethylenbiguanide solution, 75% rate of a complete wound healing was observed. In the control group the rate of healing was 52% [p=0.026, Chi square test, Figure 1]. These results indicate the high effectiveness of the Hexamethylenbiguanide as a topical agent for infected wound treatment

Purpose: Wound dressing is the last phase of any surgical intervention. The purpose is to isolate the surgical wound to reduce the risk of airborne contamination. In certain situations such as skin trauma, burns, acute or chronic loss of skin cover, or open fractures, wound dressings can however have a deleterious effect (maceration, adherence). Prevention of secondary infection of surgical wounds and spread of infection from septic patients is an integral part of our routine practice. We have developed a specific system useful in certain situations to isolate a septic or “at-risk” limb. Material and methods: Our system is composed of a closed 100-cm polyvinyl chloride isolator measuring 40 cm in diameter. Two “absolute” filters allow internal ventilation with a variable flow filtered-air generator. Sterile products are introduced into the isolator via a shuttle chamber. With this system, the wound can be isolated without isolating the patient. We have used this system for more than 250 patients since 1986. A dedicated chart has been used to monitor results obtained with the system since 1993. Results: The isolator was used for 258 patients, 185 men (71%), with 271 limb wounds on 227 lower limbs (83%) (63% legs and ankles). Half of the patients had open fractures associated with loss of skin cover. The clinical course was satisfactory in 75% of the patients (complete healing or complementary skin graft). The system was psychologically unacceptable for seven patients. There was only one case of a new germ isolated from a wound. Conclusion: This dressing isolator requires a significant “logistic” investment but provides considerable bacteriological safety for difficult cases

Aims

Increasingly, patients with bilateral hip arthritis wish to undergo staged total hip arthroplasty (THA). With the rise in demand for arthroplasty, perioperative risk assessment and counselling is crucial for shared decision making. However, it is unknown if complications that occur after a unilateral hip arthroplasty predict complications following surgery of the contralateral hip.

Abstract

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants.

Cite this article: Bone Joint J 2019;101-B:512–521.

Objectives

Irrigation is the cornerstone of treating skeletal infection by eliminating pathogens in wounds. A previous study shows that irrigation with normal saline (0.9%) and ethylenediaminetetraacetic acid (EDTA) could improve the removal of Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) compared with normal saline (NS) alone. However, it is still unclear whether EDTA solution is effective against infection with drug-resistant bacteria.

BACKGROUND: Complex tibial peri-articular fractures are known to be challenging with high complication rates. Techniques are evolving to assist the management of these injuries and this study looks at a Trauma unit’s experience to help evaluate indications, short and mid-term outcomes and complications. METHOD: 4 year retrospective analysis of prospectively enrolled patients diagnosed with complex peri-articular fractures. Definitive treatment with Less Invasive Stabilisation System (LISS), low contact peri-articular plates and locking condylar plates, using minimally invasive percutaneous osteosynthesis (MIPO), irrespective of initial operative management were included. Follow up:until discharge from clinic with union and full weight bearing. Outcome: peri- and post-operative complications, loss of fixation, radiographic union, and range of motion. RESULTS: 25 (15 proximal,10 distal tibial) operations by senior authors (RAB, SDD) over 4 years with a 16–88 year age (mean 44). Poly-trauma:7 (28%) of cases and 6 (24%) of the entire group were open fractures. Ten patients (40%): preceding damage-limitation procedure prior to definitive treatment (MIPO) and found to be over twice as likely to experience a complication compared to patients who did not. 3 (12%) of 10 had failed those alternative modalities. Overall infection rate was 24% (6 patients:2 deep wound infections; 4 open fracture wound infections). Infection was successfully managed with the use of debridement, flaps and antibiotics in 2 patients (8%); antibiotics alone on one (4%); in 3 patients with the delayed plate removal (12%), usually after union (1 revised with an intramedullary nail). Six plates (24%) were removed: 3 (12%) for infection; 2 (8%) for pain; 1 (4%) for plate fracture (revised). Other complications:2 (8%) significant wound breakdowns, one of whom required local flap cover. No mal-alignment issues; 1 patient developed common peroneal nerve neuropraxia. Patients who were operated after a week or more from injury were half (33%) as likely to suffer from a complication than those operated within a week (57%); P < 0.05 Chi-Square. All progressed to union with 5 patients (20%) having metal work out at that end point and 8 (32%) healing without complication, further surgery or irritation. There were 18 re-operations in total in 9 (36%) of the patients. CONCLUSION: Complex peri-articular fractures of the tibia continue to have a high re-operation rate with significant infection risk especially in open injury. Such techniques do provide a lower morbidity and short-term complication profile when compared with frames/hybrids and formal open fixation. The timing of minimal approach surgery is crucial and has yet to be fully defined. Within a department this type of fixation should be restricted to those with a specific interest, experience and training

Objectives

As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures.

Objectives

The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures.

Objectives

The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT).

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

Aims

Chronic osteomyelitis may recur if dead space management, after excision of infected bone, is inadequate. This study describes the results of a strategy for the management of deep bone infection and evaluates a new antibiotic-loaded biocomposite in the eradication of infection from bone defects.

In this retrospective observational cohort study, we describe 17 patients out of 1775 treated for various fractures who developed mycobacterium tuberculosis (MTB) infection after surgery. The cohort comprised 15 men and two women with a mean age of 40 years (24 to 70). A total of ten fractures were open and seven were closed. Of these, seven patients underwent intramedullary nailing of a fracture of the long bone, seven had fractures fixed with plates, two with Kirschner-wires and screws, and one had a hemiarthroplasty of the hip with an Austin Moore prosthesis. All patients were followed-up for two years. In all patients, the infection resolved, and in 14 the fractures united. Nonunion was seen in two patients one of whom underwent two-stage total hip arthroplasty (THA) and the other patient was treated using excision arthoplasty. Another patient was treated using two-stage THA. With only sporadic case reports in the literature, MTB infection is rarely clinically suspected, even in underdeveloped and developing countries, where pulmonary and other forms of TB are endemic. In developed countries there is also an increased incidence among immunocompromised patients. In this paper we discuss the pathogenesis and incidence of MTB infection after surgical management of fractures and suggest protocols for early diagnosis and management.

Cite this article: Bone Joint J 2015;97-B:1279–83.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection.

Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination.

While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared.

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75).

All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.

We identified 16 patients with a mean age of 56.5 years (31 to 86) from a large consecutive series of patients with proximal humeral fractures over a 15-year period, who had sustained a fracture with skin compromise after a blunt injury. The study group represented 0.2% of 7825 proximal humeral fractures treated during this period and all had a displaced Neer two-part fracture pattern. Two patterns of skin injury were identified: in ten patients there was skin penetration at the time of the original injury, and the other six patients initially had closed injuries. These six patients had fracture fragments penetrating the muscular envelope to lie subcutaneously producing either early skin tethering (two patients) or delayed skin penetration and sinus formation (four patients). The pattern of injury to the soft-tissue envelope and the fracture pattern were similar for all injuries. Treatment of these injuries was determined by the initial severity of the soft-tissue injury and the medical status of the patient. We currently favour open reduction and internal fixation of these fractures wherever possible, owing to the high rate of nonunion with non-operative management.

The June 2013 Foot & Ankle Roundup³⁶⁰ looks at: soft-tissue pain following arthroplasty; pigmented villonodular synovitis of the foot and ankle; ankles, allograft and arthritis; open calcaneal fracture; osteochondral lesions in the longer term; severe infections in diabetic feet; absorbable first ray fixation; and showering after foot surgery.

The February 2013 Trauma Roundup³⁶⁰ looks at: the risk of ankle fractures; absorbable implants; minimally invasive heel fracture fixation; pertrochanteric fractures; arthroplasty and intracapsular hip fractures; and extensor mechanism disruption.

Periprosthetic joint infection (PJI) is a devastating complication which can follow a total joint arthroplasty (TJA). Although rare, this ongoing threat undermines the success of TJA, a historically reputable procedure. It has haunted the orthopedic community for decades and several ongoing studies have provided insights and new approaches to effectively battle this multilayered problem.

Heterotopic ossification (HO) is perhaps the single most significant obstacle to independence, functional mobility, and return to duty for combat-injured veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Recent research into the cause(s) of HO has been driven by a markedly higher prevalence seen in these wounded warriors than encountered in previous wars or following civilian trauma. To that end, research in both civilian and military laboratories continues to shed light onto the complex mechanisms behind HO formation, including systemic and wound specific factors, cell lineage, and neurogenic inflammation. Of particular interest, non-invasive in vivo testing using Raman spectroscopy may become a feasible modality for early detection, and a wound-specific model designed to detect the early gene transcript signatures associated with HO is being tested. Through a combined effort, the goals of early detection, risk stratification, and development of novel systemic and local prophylaxis may soon be attainable.

The June 2012 Trauma Roundup³⁶⁰ looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas.

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.

Osteoradionecrosis is a rare but recognised complication of radiotherapy. Cases have been described in the cervical spine following treatment for head and neck malignancies up to 25 years after administration of radiotherapy. We present a rare case of osteoradionecrosis affecting the L5 and S1 vertebral bodies in a 58-year-old woman who presented with low back pain 25 years after undergoing a hysterectomy with adjuvant radiotherapy for cancer of the cervix.

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities.

Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups.

No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group.

We report the long-term results of the management of neglected chronically infected total knee replacements with a two-stage re-implantation protocol. In 18 of 34 patients (53%) a resistant organism was isolated. All cases were treated by the same surgical team in a specialist centre and had a mean follow-up of 12.1 years (10 to 14). They were evaluated clinically and radiologically using the Knee Society Score (KSS) and the American Knee Society Roentgenographic scoring system, respectively. One patient died after eight years from an unrelated cause and two were lost to follow-up. Three patients (8.8%) developed a recurrent infection for which further surgery was required. The infection was eradicated successfully in 31 patients (91.1%). There was one case of aseptic loosening after 13 years. We found a significant improvement in the KSS at final follow-up (p < 0.001).

Modern principles for the treatment of open fractures include stabilisation of the bone and management of the soft tissues. Wound debridement and irrigation is thought to be the mainstay in reducing the incidence of infection. Although numerous studies on animals and humans have focused on the type of irrigation performed, little is known of the factors which influence irrigation. This paper evaluates the evidence, particularly with regard to additives and the mode of delivery of irrigation fluid.

Normal saline should be used and although many antiseptics and antibiotics have been employed, no consensus has been reached as to the ideal additive. Despite the advocates of high-pressure methods highlighting the improved dilutional ability of such techniques, the results are inconclusive and these irrigation systems are not without complications.

New systems for debridement are currently being investigated, and an ideal method has yet to be determined.

Deep prosthetic joint infection remains an uncommon but serious complication of total hip replacement. We reviewed 24 patients with recalcitrant hip wounds following infected total hip replacement treated with either pedicled rectus femoris or vastus lateralis muscle flaps between 1998 and 2009. The mean age of the patients was 67.4 years (42 to 86) with ten men and 14 women.

There had been a mean of four (1 to 8) previous attempts to close the wound. A total of 20 rectus femoris and five vastus lateralis flaps were used, with one of each type of flap failing and requiring further reconstruction. All patients had positive microbiology. At a mean follow-up of 47 months (9 to 128), 22 patients had a healed wound and two had a persistent sinus. The prosthesis had been retained in five patients. In the remainder it had been removed, and subsequently re-implanted in nine patients. Six patients continued to take antibiotics at final follow-up.

This series demonstrates the effectiveness of pedicled muscle flaps in healing these infected wounds. The high number of previous debridements suggests that these flaps could have been used earlier.

We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions.

The patient’s mobility with a prosthesis is similar to that expected of a through-hip amputee.

The February 2013 Foot & Ankle Roundup³⁶⁰ looks at: replacement in osteonecrosis of the talus; ankle instability in athletes; long-term follow-up of lateral ankle ligament reconstruction; an operation for Stage II TPD; whether you should operate on Achilles tendon ruptures; Weil osteotomies and Freiberg’s disease; MRI scanning not sensitive for intra-articular lesions; and single-stage debridement and reconstruction in Charcot feet.

Open reduction and internal fixation of high-energy pilon fractures are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. A total of 17 consecutive patients with pilon fractures of AO/OTA type 43-B3 (n = 1), type C2 (n = 12) and type C3 (n = 4) were treated by indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov fixator. The calcaneal ring was removed at a mean of 3.7 weeks (3 to 6). A total of 16 patients were available for follow-up at a mean of 29 months (23 to 43). The mean time to healing was 15.8 weeks (13 to 23). Nine patients had pin-track infections but none had deep infection or osteomyelitis. Four patients (25%) had malunion. Fair, good or excellent ankle scores were found in 14 patients. External fixation with a ring fixator achieves stable reduction of the fractured fragments without additional trauma to soft tissues.

With minimum complications and good healing results, the Ilizarov apparatus is particularly useful for high-energy pilon fractures.

We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.

We present a series of 114 patients with microbiologically-proven chronically-infected total hip replacement, treated between 1991 and 2004 by a two-stage exchange procedure with antibiotic-loaded cement, but without the use of a prolonged course of antibiotic therapy. The mean follow-up for all patients was 74 months (2 to 175) with all surviving patients having a minimum follow-up of two years. Infection was successfully eradicated in 100 patients (87.7%), a rate which is similar to that reported by others, but where prolonged adjuvant antibiotic therapy has been used. Using the technique described, a prolonged course of systemic antibiotics does not appear to be essential and the high cost of the administration of antibiotics can be avoided.

Although mechanical stabilisation has been a hallmark of orthopaedic surgical management, orthobiologics are now playing an increasing role. Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline. The platelet α granules are rich in growth factors that play an essential role in tissue healing, such as transforming growth factor-β, vascular endothelial growth factor, and platelet-derived growth factor. PRP is used in various surgical fields to enhance bone and soft-tissue healing by placing supraphysiological concentrations of autologous platelets at the site of tissue damage. The easily obtainable PRP and its possible beneficial outcome hold promise for new regenerative treatment approaches.

The aim of this literature review was to describe the bioactivities of PRP, to elucidate the different techniques for PRP preparation, to review animal and human studies, to evaluate the evidence regarding the use of PRP in trauma and orthopaedic surgery, to clarify risks, and to provide guidance for future research.

We describe the results of 287 intra-articular fractures of the calcaneum in 247 patients treated by minimally-invasive reduction and K-wire fixation between 1994 and 2003. There were 210 men (85%) and 37 women (15%). The most common cause of injury was a fall from a height in 237 patients (96%). Fracture classification was based on the method described by Sanders and Essex-Lopresti. All patients were operated on within 21 days of injury and 89% (220) within 48 hours. The reduction was graded as nearly anatomical (less than 2 mm residual articular displacement and satisfactory overall alignment) in 212 (73.9%) fractures.

There were 20 cases (7%) of superficial pin-track infection and five (1.7%) of deep infection. All healed at a mean of 6 weeks (3 to 19). Loss of reduction was observed in 13 fractures (4.5%) and a musculocutaneous flap was needed in three (1%).

The results were evaluated in 176 patients (205 fractures) with a mean age of 44.3 years (13 to 67), available for follow-up at a mean of 43.4 months (25 to 87) using the Creighton-Nebraska Health Foundation Assessment score. The mean score was 83.9 points (63 to 100). There were 29 (16.5%) excellent, 98 (55.7%) good, 26 (14.8%) fair and 23 (13%) poor results. A total of 130 patients (73.9%) were able to return to their original occupation at a mean of 5.6 months (3.2 to 12.5) after the injury.

Semi-open reduction and percutaneous fixation is an effective treatment for displaced intra-articular fractures of the calcaneum.