Introduction. Fracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction. Materials & Methods. A retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management. Results. A total of 40 patients were identified, 80% of whom were male (n= 32). The mean age for FRI diagnosis was 54 years (range 18–83 years). In our patient cohort, 10% were immunosuppressed and another 12.5% had a formal diagnosis of Diabetes Mellitus. A diagnosis of acute FRI (i.e. < six weeks from time of injury) was made in 9 patients (22.5%). Chronic FRI was noted in 25 patients (62.5%). There was equal incidence of FRI in patients with closed fractures and open fractures (42.5%). Tibia and fibula fractures were most common (87.5%, n=35). Regardless of fractured bone(s), the more distal the fracture the higher the incidence of FRI (60% distal versus 12.5% proximal). Gram-positive cocci were the most commonly identified pathogens, identified in 25% of patients. Five patients underwent free flap reconstruction, two patients received pedicled muscle flaps and another two patients received split thickness skin grafts. Conclusions. The diagnosis of FRI can be confirmed through the presence of a combination of confirmatory and suggestive criteria. We advocate a staged approach in the management of FRI with radical wound excision and temporary coverage followed by definitive soft tissue reconstruction

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

Introduction. Intramedullary nailing is gaining popularity for treatment of distal tibial fractures due to short operative time and minimum surgical trauma to soft tissues. Distal tibial fractures are commonly associated with concurrent fibular fractures at, above or below the level of tibial fractures. So far there is no consensus for fixation of fibular fractures. Materials and Methods. Fractures of fibula at or below the level of fracture of tibia were taken into consideration. Fractures of fibula above the tibial level were excluded because they do not add to stability of fracture fixation. Retrospective study was done and distal tibia-fibula fractures were separated into 2 groups based on whether fibula was fixed or not. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Results. 35 fracture of distal tibia and fibula were included in study. Fibula was not fixed in 21 cases while 14 fibular fixations were carried out either using short plates(8) or intramedullary pins(6). No significant differences were observed for malalignment in fracture of fibula at the level of tibial fractures. However for fractures of fibula at a level lower than its tibial counterpart, fixation of fibula significantly reduced malalignment. Conclusion. Fixation of fibula has a definite role in reducing malunion in cases where fibula was fractured below the level of tibial fracture. Fixation of fibula may increase overall stability of fixation of tibia and reduce malunion

Approximately 20% of patients with ankle fracture sustain syndesmosis injury. This is most common in trans-syndesmotic (type B) and supra-syndesmotic (type C) fibula fractures. Intra-operative assessment of syndesmosis integrity is important because failure to treat these injuries can result in ankle instability and pain. Our aim was to audit the documentation of intra-operative testing of syndesmosis during ankle fracture open reduction and internal fixation (ORIF). All patients who had ankle fracture ORIF between 1/1/2010 and 21/11/2011 were included. Pre-operative radiographs were reviewed and fractures were classified according to AO classification. Operation notes were reviewed for documentation of assessment of syndesmosis integrity. 153 patients, of mean age 50 years (15–93) were included. 60% (n=92) were female. In 78% of cases (n=119), an assessment of syndesmosis integrity was documented in the operation note. Of the patients with no documented syndesmosis assessment (n=35), the majority had type B fractures (n=34). One patient had a type C fracture. We have shown that 22% of patients undergoing ankle ORIF for fracture do not have documented assessment of syndesmosis integrity. We suggest that all patients who have ankle ORIF should have intra-operative assessment and documentation of syndesmosis integrity so these injuries are identified and treated accordingly

We describe a new surgical approach designed for use with minimally invasive fixation and a circular frame. Tibial pilon injuries are often associated with significant soft tissue injury, which may not be evident at the time of injury. In such cases standard surgical approaches can lead to problems with wound healing, thus increase the risk of deep infection. AO Type C valgus fractures are commonly associated with fibula fractures. We found that the anterior syndesmotic ligaments are often disrupted with sparing of the lateral soft tissue envelope. Our technique utilizes a direct lateral approach to expose the lateral malleolus/distal fibula, which is reflected postero-laterally through the fracture and intact posterior syndesmotic ligaments. This creates a direct view of posterolateral and anterolateral comminution and talar dome allowing direct fixation of fragments with minimal internal fixation. Fibula fixation is performed with a 1/3. rd. tubular plate and the anterior syndesmotic ligaments are repaired. From 2007–2009, we used this approach in 12 patients (Male 9: Female 3; age 19–42) with AO Type C3 fractures with significant soft tissue injury (open = 2/ closed = 10; Tscherne Grade 1 = 4; Grade 2 = 8). We used circular frame stabilization in all cases (in four patients an additional foot frame was applied to protect the articular surface). All fractures united in satisfactory alignment. Wound healed well in all cases. One case of gouty arthritis developed superficial infection, which went on to heal after wound wash out and oral antibiotic therapy. Follow-up (minimum 3 months and maximum 2 years) showed no ankle instability. Clinical evaluation revealed a mean dorsiflexion of 10° (5–15°) and mean plantar flexion of 35° (15–60°). We conclude that transfibular approach gives good exposure of lower tibial articular surface in selected cases of pilon fractures with least soft tissue disruption