Aim. Pre-operative distinction between prosthetic joint infections (PJI) and non-infectious causes of joint failure is particularly challenging, especially in chronic situations. Guidelines propose different algorithms using numerous preoperative tests. We evaluated place of serology. Method. During a 9 month period, we included consecutive patients undergoing arthroplasty revision for a suspected chronic hip or knee infection. Serologies were sampled at the same day than the other blood tests. Results were compared with the final diagnosis, determined with peroperative bacteriological and histological results. Serology was performed using a multiplex antibody detection*. This multiplex antibody detection assay detects antibodies against Staphylococcus species, Propionibacterium acnes and Streptococcus agalactiae. Results. A total of 52 patients were enrolled. Median time from last arthroplasty was 30 months (extremes 8 months − 17 years). Median clinical signs duration was 6 months (extremes 1 – 40 months). Median CRP value was 6 mg/l (extremes 2 – 150) and sedimentation rate 12 mm (extremes 2 – 82). Diagnostic of PJI was finally retained for 17 patients and ruled out for 35. It was Staphylococcus aureus 3 times, coagulase negative staphylococci (CoNS) 5 times, P. acnes 4 times, candida sp. 2 times, Streptococcus agalactiae one time, Enterobacter cloacae one time and undetermined one time. Serology was concordant and accurate with the final diagnosis for 38 patients (27 sterile and 11 infected). For 7 of them, serology was the key parameter. In these cases, a CoNS or a P. acnes was isolated per-operatively on a single culture, out of 5 samples. Serology allowed confirming a contamination in 5 cases; and in 2 cases, even if not fulfilling the definition, it determined a PJI. In this study, serology had a global sensitivity of 65%, 77% specificity, 58% positive predictive value, and 82% negative predictive value. Serology reached 89% sensitivity with unchanged specificity in the subgroup of 11 patients with a CRP > 10 mg/l. Conclusions. We evaluated place of serology in the most complex cases of suspected chronic PJIs, with finally, only 33% cases with an infection. Modest results of serology can be explained because antigens included in the assay were not those expressed in sessile bacteria. And by persistence of a humoral response, witnesses of past infections, for patients who had past surgeries on the joint. However, simple and practical, when combined with all other parameters, serology could provide a valuable support in preoperative evaluation of chronic PJIs. * BJI InoplexTM

Aims. Post-traumatic osteoarthritis (PTOA) is a subset of osteoarthritis (OA). The gut microbiome is shown to be involved in OA. However, the effect of exercise on gut microbiome in PTOA remains elusive. Methods. A total of 18 eight-week Sprague-Dawley rats were assigned into three groups: Sham/sedentary (Sham/Sed), PTOA/sedentary (PTOA/Sed), and PTOA/treadmill-walking (PTOA/TW). PTOA model was induced by transection of the anterior cruciate ligament (ACLT) and the destabilization of the medial meniscus (DMM). Treadmill-walking (15 m/min, 30 min/d, five days/week for eight weeks) was employed in the PTOA/TW group. The response of cartilage, subchondral bone, serology, and gut microbiome and their correlations were assessed. Results. Eight-week treadmill-walking was effective at maintaining the integrity of cartilage-subchondral bone unit and reducing the elevated systematic inflammation factors and microbiome-derived metabolites. Furthermore, 16S ribosomal ribonucleic acid (rRNA) sequencing showed disease-relevant microbial shifts in PTOA animals, characterized by the decreased abundance of phylum TM7 and the increase of phylum Fusobacteria. At the genus level, the abundance of Lactobacillus, Turicibacter, Adlercreutzia, and Cetobacterium were increased in the PTOA animals, while the increase of Adlercreutzia and Cetobacterium was weakened as a response to exercise. The correlation analysis showed that genus Lactobacillus and Adlercreutzia were correlated to the structural OA phenotypes, while phylum Fusobacteria and genus Cetobacterium may contribute to the effects of exercise on the diminishment of serological inflammatory factors. Conclusion. Exercise is effective at maintaining the integrity of cartilage-subchondral bone unit, and the exercise-induced modification of disease-relevant microbial shifts is potentially involved in the mechanisms of exercise-induced amelioration of PTOA. Cite this article: Bone Joint Res 2022;11(4):214–225

The aim of our study was to describe the characteristics, treatment, and outcomes of patients with periprosthetic joint infection (PJI) and normal inflammatory markers after total knee arthroplasty (TKA) and total hip arthroplasty (THA). . In total 538 TKAs and 414 THAs underwent surgical treatment for PJI and met the inclusion criteria. Pre-operative erythrocyte sedimentation rate (ESR) and C-reactive protein level (CRP) were reviewed to identify the seronegative cohort. An age- and gender-matched cohort was identified from the remaining patients for comparison. Overall, 4% of confirmed infections were seronegative (21 TKA and 17 THA). Of those who underwent pre-operative aspiration, cultures were positive in 76% of TKAs (n = 13) and 64% of THAs (n = 7). Cell count and differential were suggestive of infection in 85% of TKA (n = 11) and all THA aspirates (n = 5). The most common organism was coagulase-negative Staphylococcus. Seronegative infections were associated with a lower aspirate cell count and a lower incidence of Staphylococcus aureus infection. Two-stage revision was performed in 35 cases (95%). At a mean of five years (14 to 162 months) following revision, re-operation for infection occurred in two TKAs, and one THA. From our study we estimate around 4% of patients with PJI may present with normal ESR and CRP. When performed, pre-operative aspirate is useful in delivering a definitive diagnosis. When treated, similar outcomes can be obtained compared with patients with positive serology. Cite this article: Bone Joint J 2015;97-B:939–44

Aims

To investigate the optimal thresholds and diagnostic efficacy of commonly used serological and synovial fluid detection indexes for diagnosing periprosthetic joint infection (PJI) in patients who have rheumatoid arthritis (RA).

Aims. The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld. Methods. A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years. Results. None of the acute PJIs and 70 of the chronic PJIs (4.7%) were culture-negative; a total of 36 culture-negative PJIs (51%) were treated with antibiotics, particularly those with histological signs of infection. After two years of follow-up, no recurrent infections occurred in patients in whom antibiotics were withheld. The requirement for removal of the components for any indication during follow-up was not significantly different in those who received antibiotics compared with those in whom antibiotics were withheld (7.1% vs 2.9%; p = 0.431). Conclusion. When adequate methods of culture are used, the incidence of culture-negative PJIs is low. In patients with culture-negative PJI, antibiotic treatment can probably be withheld if there are no histological signs of infection. In all other patients, diagnostic efforts should be made to identify the causative microorganism by means of serology or molecular techniques. Cite this article: Bone Joint J 2022;104-B(1):183–188

Introduction and Aims: To confirm whether bacteria were present in disc material harvested at the time of discectomy; and to determine whether the presence of bacteria correlated with elevation of Anti Lipid S antibody levels; and to compare these results with antibody levels and disc specimens from patients undergoing surgery for indications other than radiculitis. We have previously demonstrated significantly elevated IgG titres (ELISA) to a glycolipid antigen found in the cell wall of most gram-positive bacteria in patients with discogenic sciatica. This raised the possibility that the inflammation associated with disc protrusion might be initiated or accelerated by bacteria. Method: A prospective study was performed using disc material harvested with stringent aseptic precautions from 207 microdiscectomy and 27 trauma, tumor or scoliosis patients (controls). Serology was obtained for all patients. Results: In the Microdiscectomy group 76/207 (37%) had positive cultures after seven days incubation, of which 26 (34%) had positive serology. Forty-nine patients had Propionibacteria, 11 Coagulase-negative-Staphylococci (CNS), eight Propionibacteria and CNS, four other organisms and four mixed growth. One hundred and thirty one (63%) patients had negative cultures of whom 15% had positive serology. There was a significant difference between patients with positive serology and culture, compared with those with negative serology and culture (Fischer exact test P< 0.01). In some patients, organisms were visible on microscopy prior to culture. Two of the patients undergoing surgery for other indications had positive cultures (P.acnes) of whom one had positive serology. Of those with negative cultures, six had positive serology. There was a significant difference between positive cultures in those with sciatica and controls (P< .001). Conclusion: A significant proportion of patients with discogenic radiculitis have positive cultures with low-virulence Gram-positive organisms (predominantly Propionibacteria ) and in proportion, a corresponding appropriate antibody response

Introduction: We have previously demonstrated significantly elevated IgG titres (ELISA) to a glycolipid antigen found in the cell wall of most gram positive bacteria in patients with discogenic radiculitis (sciatica). This raised the possibility that the inflammation associated with disc protrusion might be initiated or accelerated by the presence of bacteria. Aim of the study: To confirm whether bacteria were present in the disc material harvested at the time of discectomy. To determine whether the presence of bacteria correlated with elevation of Anti Lipid S antibody levels. To compare these results with Antibody levels and disc specimens from patients undergoing surgery for indications other than radiculitis. Methods: This was a prospective study. Recognising the frequency of contamination in clean wound culture stringent aseptic precautions were taken. Disc material was harvested from 108 microdiscectomy patients with sciatica. Disc material was also obtained from 11 patients undergoing discectomy for other indications (trauma, tumour scoliosis). Serology was obtained for all these patients. Results: In the microdiscectomy group 50/112 (45%) had positive cultures after seven days incubation, of which 15 (30%) had positive serology. Thirty-one patients had Propionibacteria, nine Coagulase negative Staphylococci (CNS), six Propionibacteria and CNS, one Corynebacterium and three mixed growth. Sixty-two (55%) patients had negative cultures and all except one had negative serology. There was a significant difference between patients with positive serology and culture compared with those with negative serology and culture (Fischer exact test P< 0.01). In some patients organisms were visible on microscopy prior to culture. Thirteen of those with postive cultures and 25 of those with negative cultures had had one or more epidural injections prior to surgery. Epidural injection was not found to be significantly associated with postive culture. None of the patients undergoing surgery for other indications had positive serology or positive cultures. Conclusion: A significant proportion of patients with discogenic radiculitis have positive cultures with low virulence Gram positive organisms (predominantly Propionibacteria) and in a proportion a corresponding appropriate antibody response

Introduction: We have previously demonstrated significantly elevated IgG titres (ELISA) to a glycolipid antigen found in the cell wall of most gram positive bacteria in patients with discogenic radiculitis (sciatica). This raised the possibility that the inflammation associated with disc protrusion might be initiated or accelerated by the presence of bacteria. Aim of the Study: To confirm whether bacteria were present in disc material harvested at the time of discectomy. To determine whether the presence of bacteria correlated with elevation of Anti Lipid S antibody levels. To compare these results with Antibody levels and disc specimens from patients undergoing surgery for indications other than radiculitis. Methods: This was a prospective study. Recognising the frequency of contamination in clean wound culture, stringent aseptic precautions were taken. Disc material was harvested from 62 microdiscectomy patients with sciatica. Disc material was also obtained from three patients undergoing decompression but without radiculitis and from three patients undergoing anterior correction of scoliosis. Serology was obtained for all these patients. Results: In the Microdiscectomy group, 27/62 (43%) had positive cultures after seven days incubation, of which nine (33%) had positive serology. 22 patients had Propionibacteria, three Coagulase negative Staphylococci, one Corynebacterium and one mixed growth. Thirty five (56.4%) patients had negative cultures and all except one had negative serology. There was a significant difference between patients with positive serology and culture compared with those with negative serology and culture (Fischer exact test P< 0.001). In some patients organisms were visible on microscopy prior to culture. Ten of those with positive cultures and fourteen of those with negative cultures had had one or more epidural injections prior to surgery. Epidural injection was not found to be significantly associated with positive culture. None of the patients undergoing surgery for other indications had positive serology or positive cultures. Conclusion: A significant proportion of patients with discogenic radiculitis have positive cultures with low virulence Gram positive organisms (predominantly Propionibacteria) and in a proportion, a corresponding appropriate antibody response

Aims. To establish the utility of adding the laboratory-based synovial alpha-defensin immunoassay to the traditional diagnostic work-up of a prosthetic joint infection (PJI). Methods. A group of four physicians evaluated 158 consecutive patients who were worked up for PJI, of which 94 underwent revision arthroplasty. Each physician reviewed the diagnostic data and decided on the presence of PJI according to the 2014 Musculoskeletal Infection Society (MSIS) criteria (yes, no, or undetermined). Their initial randomized review of the available data before or after surgery was blinded to each alpha-defensin result and a subsequent randomized review was conducted with each result. Multilevel logistic regression analysis assessed the effect of having the alpha-defensin result on the ability to diagnose PJI. Alpha-defensin was correlated to the number of synovial white blood cells (WBCs) and percentage of polymorphonuclear cells (%PMN). Results. Intraobserver reliability and interobserver agreement did not change when the alpha-defensin result was available. Positive alpha-defensin results had greater synovial WBCs (mean 31,854 cells/μL, SD 32,594) and %PMN (mean 93.0%, SD 5.5%) than negative alpha-defensin results (mean 974 cells/μL, SD 3,988; p < 0.001 and mean 39.4% SD 28.6%; p < 0.001). Adding the alpha-defensin result did not alter the diagnosis of a PJI using preoperative (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.14 to 1.88; p = 0.315) or operative (OR 0.52, CI 0.18 to 1.55; p = 0.242) data when clinicians already decided that PJI was present or absent with traditionally available testing. However, when undetermined with traditional preoperative testing, alpha-defensin helped diagnose (OR 0.44, CI 0.30 to 0.64; p < 0.001) or rule out (OR 0.41, CI 0.17 to 0.98; p = 0.044) PJI. Of the 27 undecided cases with traditional testing, 24 (89%) benefited from the addition of alpha-defensin testing. Conclusion. The laboratory-based synovial alpha-defensin immunoassay did not help diagnose or rule out a PJI when added to routine serologies and synovial fluid analyses except in cases where the diagnosis of PJI was unclear. We recommend against the routine use of alpha-defensin and suggest using it only when traditional testing is indeterminate. Cite this article: Bone Joint J 2020;102-B(5):593–599

Background. Revision total knee arthroplasty (rTKA) is a complex procedure with increased risk of blood loss and transfusions. The Musculoskeletal Infection Society has included D-dimer as a serology marker for peri-prosthetic infection. The study's intent is to understand the impact of preoperative D-dimer levels on blood loss and venous thromboembolism in revision TKA. Methods. Following IRB approval, rTKA performed by a single surgeon between January 1, 2017 and December 31, 2019 were reviewed. Inclusion criteria consisted of pre-operative D-Dimer, cemented revision TKA of one or both components under tourniquet control. 89 patients met the criteria including 37 males (41.6%) and 52 females (58.4%). Mean ages were 65 for males and 67 for females. The data revealed 54 patients (61%) had an elevated D-dimer (group 1) and 35 patients (39%) had a normal D-dimer (group 2). Sex stratification showed 21 males (57.8%) and 33 females (63.5%) with elevated D-dimer. TXA protocol included 2 grams intravenous (82 patients) or 2 grams intra-articular application (7 patients). Post-operative anticoagulation included Lovenox 40mg daily for 2 weeks followed by aspirin 325 twice daily for 4 weeks. Pre-operative and post-operative hemoglobin, transfusion rates and post-operative VTE within 90 days of surgery were recorded. Results. The mean pre-operative hemoglobin (hgb) was 13.30 and post-operative was 11.21. The mean change in hgb for males was 2.75 and for females 1.91. Both male and female cohorts had an acceptable range and the change in hgb was not statistically significant (p=0.076). Two female patients (2.25%) were transfused, both receiving IV TXA and their pre-operative hgb was lower than the cohort. No VTE events were identified in either groups of patients within the 90 day post-operative period. Conclusion. This study revealed that TXA is effective in reducing blood loss following rTKA and an elevated D-dimer is not a contraindication to its use

Purpose of the study: Echinococcosis is an anthropozoonosis with a predominantly muscular, more rarely osteoarticular, localisation. The purpose of this work was to describe the conditions of discovery, the diagnostic management, the serology and pathology findings, and the results of surgical treatment as well as potential complications. Material and methods: We collected over a 16-year period, 14 cysts in eight women and six men. Mean age was 39 years (range 17–75) and delay to consultation was 36 months. The patients had an ultrasound (all 14 cases), computed tomography (n=7), MRI (n=7), hydatid serology (n=9) and pathology examination (n=10). All patients were treated surgically (7 complete resection); one patient was given associated medical treatment for a multiple localisation. Results: Muscle hydatisosis occurred in all cases as a medium-sized tumour (mean 9 cm, range 5–16 cm) which was painful in half of the cases. One cyst was superinfected and one patient had a neurological complication. The most common site was the adductor compartment of the thigh (5 cases). Four patients had an associated visceral localization. At mean 4 years follow-up, one patient had a superinfection and two others recurrence at 7 and 10 months, with surgical revision and good outcome. Discussion: The risk vascularisation of the thigh muscles explains these localisations. Ultrasound is a sensitive exploration which suggests the diagnosis in all cases. CT and MRI confirm the diagnosis and define the cyst relations. Pathology is needed for formal diagnosis. Total pericystectomy or wide resection is the best surgical technique, although not always readily achieved. Conclusion: Muscle hydatidosis is rare. Treatment is surgical, different from the osteoarticular localisation, similar to the visceral foci. Recurrence is exceptional. Prevention remains the best treatment

Femoral head allograft bone used in complex orthopaedic surgery may transmit infection from donor to recipient. In order to minimise the risk all donors are serologically screened for Hepatitis B and C, HIV, HTLV, and syphilis at the time of donation and again at 6 months post-donation. Culture swabs are taken from the acetabulum and femoral head for 48 hour anaerobic and aerobic culture, and a sample of bone is incubated for 5 days in enrichment broth culture. We have audited the culture results and screening tests performed in our bone bank from 2000 to 2005 inclusive. 1,528 allografts were received of which we had to discard 52 (3.4%) because of either positive cultures or serology. The vast majority of the positive cultures were due to S. epidermidis (30/43). All cultures were bacteria one might expect to find as normal skin flora. 3 patients had positive hepatitis C serology and 6 were syphilis EIA positive. In May 2004 we decided in line with National Transfusion Guidelines for blood donation, to exclude donors who had had a blood transfusion since 1980 to mini-mise the risk of transmission of CJD. This and the opening of an Independent Treatment Centre (ITC) in our area drastically limited the number of possible donors to our bone bank. There was a significant reduction in the number of femoral heads received in 2004 and 2005 when compared with years 2000-2003 (p = < 0.00001). We conclude that negligible numbers of femoral head allografts are lost due to our serological and microbio-logical screening tests. However measures introduced to limit the theoretical transmission of CJD via a bone allograft and the opening of a local ITC have had a huge impact on the number of potential donors available to us. To date the CJD prion has not been isolated from bone, but there have been 3 reported cases of transmission of infection by blood transfusion. We fear that the imminent introduction of a serological test for CJD will limit the number of possible bone donors even further

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

Aim. In an earlier study we identified severe Vitamin D deficiency as a problem in institutionalised children with cerebral palsy (CP), which resulted in rickets and a high incidence of fractures. The purpose of this study was to establish whether a cohort of non-ambulatory children with CP, living at home, presented with Vitamin D deficiency. Method. The participants were a consecutive sample (N=100) of non-ambulatory children with CP attending a CP outpatient clinic. Their ages ranged from 2 to 15 years (mean 5.8, SD 3.3 years). There were 57 males and 43 females. Nineteen were on Level IV of the Gross Motor Function Classification System (GMFCS), and 81 were on Level V. 66% were on anticonvulsant therapy (ACT). Basic demographic data was collected, and measurements included blood sample analysis and wrist radiographs. There was radiographic evidence of osteopenia and delayed ossification of the carpal bones. Results. Three participants had Vitamin D deficiency rickets confirmed by wrist changes and serology. There was a significantly higher level of Alkaline Phosphatase (p=0.04) in children on ACT than in those who did not receive ACT. Preliminary results show that one third of the children had Vitamin D deficiency. Conclusion. Non ambulatory children with CP are at risk of developing rickets. We recommend regular exposure to sunlight or Vitamin D supplementation as preventative measures. NO DISCLOSURES

Osteomyelitis is usually related to trauma, surgery, immunocompromised patients, IV drug abuse, poor vascular supply, diabetes, sickle cell disease or peripheral neuropathy. We report an unusual case of femur osteomyelitis without any of these risk factors. A 31 years old male, light smoker, presented at the Emergency Room for pain in the left thigh for about a month, without any previous event. He had 2 previous visits to the hospital with similar diffuse complaints interpreted as irradiated low back pain. He was pale, feverish but no signs of local inflamation. His left knee ROM was 30°-15°-0°. He had no neurologic deficits. Blood tests showed high WBC count and PCR (400mg/L). After contrasted CT showing an 1,2×6×2,5cm abcess the patient was taken to the OR for irrigation and debridment. The day after the patient did a MRI that showed extended femur osteomyelitis and adjacent myositis (images). He underwent new surgery for a more extensive irrigation and debridment, femur medular canal included, from where a large pus quantity erupted. The hemocultures and bone biopsys, revealed a Multissensible Strep. Alfa-hemolitic (S. anginosus) and appropriate antibiotherapy was implemented (Amoxicillin/Clavulanate). He slowed improve till 11th day when he showed rise of PCR and a new MRI showed the same inflammatory process. He underwent new surgery but no pus was visible. He gradually improved, started hyperbaric oxygen therapy and was discharged on the 28th day after the first surgery, continuing antibiotherapy at home for a total of 8 weeks. Transthoracic Ecography was normal, as well Brucella, HIV, and other serologies. Three weeks later, the patient again presented to the ER with fever and rise of inflammatory markers in blood, consistent with recurrence of the infection. The patient was taken to the OR for surgical debdridment and irrigation, but this time the cultures showed a multissensible Gemella haemolysans, possible contamination during the hyperbaric oxygen therapy sessions. This is the case of a healthy young adult with an idiopathic femur osteomyelitis, initially misinterpreted for irradiated low back pain, that recurred after the first medical and surgical successful treatment, with an unusual agent

Purpose. Severe osteo-articular infection can be a devastating disease causing local complications, multiple organ failure and death. The aim of this study is to highlight the potential severity and subsequent sequelae of osteo-articular infections in children and to determine causative factors leading to this devastating condition. Methods. We retrospectively report on six cases treated at two academic hospitals. We included all patients with osteo-articular infections who had multi-organ involvement. All patients had more than one joint as well as another organ involved as a direct result of the bacteraemia. All patients with single organ involvement were excluded. The patient files were recorded as part of a previously published study. Data capture included X-rays, serology for blood culture, FBC, ESR, CRP and HIV. Ultrasound of involved joints, technetium bone scans, echocardiograms and computed tomography of the brain were performed when indicated. Results. There was a delay in the diagnosis and subsequent treatment of all of these patients, mean duration 4.8 days(1 to 10) Twenty-two osteo-articular sites were involved mean 3,7 sites (2 to 6)and seventeen other organs mean 2,8 (2 to 5). The mean number of debridements or joint washouts for each patient was 4,5 (3 to 6). Four of the six cases cultured organisms: One Staphylococcus aureus, one Haemophilus influenzae and one Candida spp on tissue. Local complications included chronic osteomyelitis, physeal separation, pathological fractures and hip dislocation. There was one death in a nine year old HIV positive patient with severe multiple organ failure. Conclusion. A delay in the diagnosis and treatment of osteo-articular infection was identified as the causative factor leading to severe infection with life threatening complications. NO DISCLOSURES

Twenty-one patients with spinal brucellosis were reviewed. The disease is difficult to diagnose, and is often confused with spinal tuberculosis. Our study showed that it was best diagnosed by serology and bacterial culture; radiography and scanning were less helpful in the early stages. After only six weeks' antibiotic treatment, there was a 55% clinical and serological reactivation rate: better results were achieved after at least three months of treatment. The adequacy of treatment was best monitored with repeated agglutination titres, and the duration of treatment proved to be more important than the antibiotic agent itself. Surgical intervention was reserved for biopsy, severe neurological impairment, or for spinal stabilisation

Introduction. The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis. Methods. A retrospective review of cases treated consecutively from 2006 to 2010 was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36). Results. There were 31 patients (22 male, 9 female). The mean age was 47 years (20–67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staph. Aureus in 16 and Coag. Neg. Staph. in 6 cases. The median follow-up was 1.7 years (0.5–5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences. Discussion. Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%. Conclusion. Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis. A retrospective review of cases treated consecutively from 2006 to 2010 in the Royal Liverpool University Hospital was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36). There were 31 patients (22 male, 9 female). The mean age was 47 years (20-67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staphylococcus Aureus in 16 and Coagulase Negative Staphylococcus in 6 cases. The median follow-up was 1.7 years (0.5-5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences. Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%. Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis