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

Objective. The development of surgical site infection in the early weeks following open reduction and internal fixation (ORIF) is a challenging problem. There are no evidence-based guidelines to direct the number of surgical debridements prior to definitive wound closure. The purpose of this study was to assess the success of infection resolution, and to identify risk factors for failure, in post-operative infections treated with a single debridement and primary wound closure. Methods. We retrospectively reviewed 61 postoperative infections (60 patients) that developed following fracture ORIF that were treated with a single debridement and primary closure. Data was collected from a review of the patients’ medical record. Variables were compared between the two groups using univariate and multivariate logistic regression analysis. Results. Twenty nine cases (48%) in 28 patients achieved successful outcome following a single debridement and primary closure without hardware removal. Risk factors for treatment failure, identified by multivariate analysis, were AO/OTA classification B and C type fractures (odds ratio = 2.539; 95% confidence interval = 1.110, 5.807; p = 0.027) and elevated C-reactive protein at admission (odds ratio = 1.017; 95% confidence interval = 1.002, 1.032; p = 0.026). Conclusions. Acute postoperative infection following ORIF treated by a single debridement and primary closure with hardware retention is successful in only half of the cases

To describe the success rate of surgical debridement and primary closure without implant removal in the treatment of postoperative spinal wound infections with instrumentation. One thousand four hundred fifty two posterior instrumented fusions were performed between 2000 and 2006. A retrospective record review identified 63 cases with acute (< 6 weeks) postoperative infection (4.6%). The preoperative diagnosis included fracture (24), adolescent idiopathic scoliosis (4), stenosis/degenerative spondylolisthesis (24), adult deformity (4), neuromuscular scoliosis (3), tumor (2), cervical myelopathy (2). All patients were treated with irrigation – debridement and closed suction drainage placement. Cultures were obtained, all wounds closed primarily and appropriate intravenous antibiotic treatments were initiated. The treatment protocol dictated the appropriate time to discontinue drains and antibiotics. The follow-up period ranged from 6 to 24 months. The majority of infections occurred during the early postoperative period (less than 2 weeks). Fifty-six (89%) resolved without recurrence with only one surgical debridement. Seven patients (11%) required a second operation for irrigation and debridement. Two patients (3%) required implant removal. Aggressive surgical treatment of postoperative spinal infections is essential for successful outcomes. Removal of implants is not necessary in acute infections. Delayed wound closure or second look operation could be avoided since primary closure offers accepted success rate

Two cases of laterally open knee joints with surrounding skin defects are reported. The joints were closed by muscle flaps fashioned from the lateral belly of the gastrocnemius, which was detached distally and folded upwards and forwards to cover the defect. The transposed muscle and the remainder of the wound were covered by free skin grafts. Results were satisfactory.

Introduction and Aims: Primary wound closure in open tibial fractures has not been recommended. Studies suggest that infections are not caused by the initial contamination but the organisms acquired in the hospital. Primary wound closure after adequate wound care and fracture stabilisation should be a safe concept. Method: We analysed 95 patients with open tibial fractures Gustilo-Anderson Type 1-3a treated with primary fracture stabilisation and delayed wound closure (group I) and primary fracture stabilisation and primary wound closure (group II). In group I, 46 patients (38 males, eight females) with a mean age of 30.2 years (range 16–56) were included. In group II, 49 patients (36 males, 13 females) with a mean age of 33.4 (range 18–69) were included. The mean follow-up in group I was 11.5 (range 9–18) and 11.7 (range 8–16) months. Results: The mean operating time in group I was 96 (range 45–180) minutes, in group II, 101 (range 40–170) minutes. The hospital stay in group I was 8.6 (range 3–20) days and in group II, 15.4 (range 4–52) days. One infectious case in group I was seen (2%) and two cases in group II (4.3%) were found. On further analysis, one case in group II, in our opinion, should not have been treated with primary fixation and wound closure. He only had three doses of a first generation cephalosporin and was operated 20 hours after admission to hospital. The corrected infection rate in group II should therefore should be calculated without that case and then is 2.1%. Conclusions: Our results support recent findings that primary wound closure after thorough debridement in Grade I and II open fractures does not increase the infection rate in comparison to the standard treatment. It shortens hospital stay and is cost-effective treatment. We conclude that primary wound closure is safe

Limited forefoot amputation in diabetic patients with osteomyelitis is frequently required. We retrospectively reviewed diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe of > 45 mmHg who underwent limited amputation of the foot with primary wound closure. Between 2006 and 2012, 74 consecutive patients with a mean age of 67 years (29 to 93), and a median follow-up of 31 months, were included. All the wounds healed primarily at a median of 37 days (13 to 210; mean 48). At a median of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered a further ulceration. Of these, 12 patients (16% of the total) required a further amputation. We conclude that primary wound closure following limited amputation of the foot in patients with diabetes is a safe and effective technique when associated with appropriate antibiotic treatment. Cite this article: Bone Joint J 2013;95-B:1083–7

Introduction. Primary wound closure in open tibial fractures has not been recommended. Traditionally initial debridement with fracture stabilisation and delayed wound closure was the accepted treatment. However this practice was developed before the use of prophylactic intravenous antibiotics and improved techniques for fracture stabilisation. Studies suggest that infections are not caused by the initial contamination but the organisms acquired in the hospital. Subsequent primary wound closure after adequate wound care and fracture stabilisation should be a safe concept and should not increase the rate of complications. Material/methods. In a retrospective study we analysed 95 patients with open tibial fractures Gustilo-Anderson Type 1-3a treated at two different teaching hospitals with primary fracture stabilisation and delayed wound closure as group I and primary fracture stabilisation and primary wound closure as group II. Exclusion criteria to the study were the following conditions: Grade 3b and 3c fractures, polytrauma, other fractures, significant medical history, previous surgery 6 months prior to admission. In group I 46 patients (38 males, 8 females) with a mean age of 30.2 years (16-56) were included. 19 sustained Grade 1 open, 16 Grade 2 open, 4 Grade 3a open and 7 gunshot fractures to the shaft of the tibia. In group II 49 patients (36 males, 13 females) with a mean age of 33.4 (18-69) were included. 19 sustained Grade 1 open, 19 Grade 2 open, 3 Grade 3a open and 8 gunshot fractures. The mean follow-up in group 1 was 11.5 (9-18) and 11.7 (8-16) months. The criteria for post-operative infection were clinical/radiological. Results. The mean operating time in group 1 was 96 (45-180) minutes, in group II 101 (40-170) minutes. The hospital stay in group 1 was 8.6 (3-20) days and in group 2 15.4 (4-52) days. One infectious case in group 1 was seen (2%) and two cases in group 2 (4.3%) were found. On further analysis one case in group 2 in our opinion should not have been treated with primary fixation and wound closure. He only had 3 doses of a first generation cephalosporin and was operated 20 hrs after admission to hospital. The corrected sepsis rate in group 2 should therefore should be calculated without that case and then is 2.1%. Discussion. Our results support recent findings that primary wound closure after thorough debridement in Grade 1+2 open fractures does not increase the infection rate in comparison to the standard treatment. It shortens hospital stay and is cost effective treatment. We conclude that primary wound closure is safe. Prospective multicentre studies are needed to further evaluate and result in change of the current practice

Purpose: Resection of pelvic sarcoma with limb preservation (internal hemipelvectomy) is a major undertaking. Resection requires large areas of soft-tissue to be removed. Because of wound complications, we manage these defects with immediate tissue transfer (ITT) at the time of resection when a large defect is anticipated. This study compares the outcomes of ITT with primary wound closure (PWC). Method: Twenty patients undergoing 22 separate procedures (1995–2007) were identified in our prospectively maintained database. Demographics, tumour type, operative data and complications, and functional scores (MSTS-1993, TESS) were collected. Results: Twelve defects were managed with ITT, nine with pedicled myocutaneous vertical rectus abdominis (VRAM) flaps (one received double VRAM flaps due to the large defect), two with tensor fascia lata (TFL) rotation flaps (one augmented by local V-Y advancement, the other with gluteus maximus rotation flap) and one received latissimus dorsi free tissue transfer. Four wound complications necessitated operative intervention in this group: two debrided VRAM flaps went on to heal and the two TFL flaps required revision: one to VRAM flap and the other to a latissimus dorsi free flap which ultimately suffered chronic infection and hindquarter amputation was performed. Ten defects were managed with PWC, and 5 wound complications occurred, all five suffered infection, one developed hematoma and one dehisced. One wound resolved with debridement, two healed after revision to pedicled gracilis and gluteus maximus myocutaneous flaps. Two patients were converted to hindquarter amputation due to chronic infection. Functional scores were collected on 8 of 12 living patients, at time of writing. The mean TESS scores were 83 and 73 in the ITT and PWC groups. Five patients in the ITT and 3 in the PWC group were deceased. Conclusion: Soft-tissue closure following pelvic sarcoma resection remains a difficult challenge, and our experience reflects that. There were fewer wound complications (33% v 50%) and slightly better function with ITT than PWC, but this was not statistically significant due to the small size of our study. Although small, this study suggests ITT should be considered whenever a large soft tissue defect is anticipated

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. Methods. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results. In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing. Cite this article: Bone Jt Open 2024;5(3):236–242

Aims. To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures. Methods. We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication. Results. Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries. Conclusion. Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication. Cite this article: Bone Joint Open 2020;1-8:481–487

Purpose. Management of compound fractures, which have a higher infection risk than closed fractures, currently depends on surgeon training and past practice rather than evidence based practice. Some centres use delayed closure involving a second surgery with repeat debridement and wound closure 48 hours after initial debridement and fixation. Other centres use primary closure in the absence of gross contamination or major soft tissue deficits, where debridement, fixation and wound closure occur during the initial surgery. Delayed closure was used at our centre until January 2009 when the standard of care evolved to primary closure where appropriate. Primary closure allows more efficient OR utilization due to fewer OR visits, but it is unknown if primary closure increases the risk of infection, which can, in turn, lead to fracture non-union. The purpose of this pilot study was to complete a safety analysis of infection rates in the first 40 patients undergoing primary closure of a compound fracture; enrolment is ongoing and updated results will be presented. Method. Patients admitted in 2010 with a long bone(femur, tibia/fibula, humerus, radius/ulna) Gustilo grade I-IIIA compound fracture, without the following: gross organic contamination, compartment or crush syndrome, amputation, or gunshot wound, were eligible for primary closure at fracture fixation, and thus for study inclusion. The analysis compared primary closure subjects with matched delayed closure subjects taken from a previous prospective cohort study of >700 subjects. Subjects were matched at a one:two ratio(i.e. one primary closure:two delayed closure patients) on fracture location, Gustilo grade of fracture, age(within five years), significant comorbidities(diabetes, kidney disease and osteoporosis) and social factors(smoking and alcohol abuse). The outcomes were 1) any infection and 2) deep infection within six weeks of surgery. Time on antibiotics and length of hospital stay(LOS) was also recorded. Results. Eighteen primary closure subjects were enrolled between January and May 2010 and matched to 35 delayed closure subjects. The average age of subjects was 4212.6 years and 42(79%) were male. Postoperative infection developed in 0/18(0%) primary closure and 4/35(11.4%) delayed closure subjects within six weeks(p=0.14). Only 1/35 delayed closure subject developed deep infection within six weeks of surgery(p= 0.47). The mean time on antibiotics was 6.82.9 days in primary closure and 7.96.5 days in delayed closure subjects(p=0.50). The mean LOS was 8.47.2 days in the primary closure and 8.16.6 days in the delayed closure group(p=0.88). Conclusion. We found no infection within six weeks postoperatively in the 18 primary closure subjects while four(11.4%) of the matched delayed closure subjects developed infection, one(2.9%) of which was a deep infection. These are promising preliminary results of primary closure of open long bone fractures; further analyses are planned and a randomized trial is under development

Diabetic foot problems are a common cause for hospitalisation in this group and up to 25% of diabetic patients will be affected. Prevalence of diabetes is rising, currently affecting 680000000 people worldwide. The enormity of this problem mandates any strategy that shortens therapeutic period and enhances success rates. Cerament G has been used in our unit as a treatment adjunct in diabetic foot treatment. Successful treatment is viewed as eradication of infection and a functional foot. Retrospective review of 40 months practice with 115 patients. Inclusion: all diabetic feet requiring surgery Cerament G used, protocol driven Microbiology pathway. Exclusion: Primary closure not possible. Cerament G not used. Outcome assessed in three groups: Total failure (further surgery required); slow to heal (healing by secondary intention); healed without problems. Healed 99 (eradication of infection and return to function), failure to heal 16 (success rate: 86.1%). Infection was the cause of failure in only in 2.6% (13 failures due to patient noncompliance or poor vascularity). Accepted success rate in treating osteomyelitis in diabetic feet is 68% (medical treatment only), combination of surgery and medical is 86%. Eradication of infection is the only end point return to function is not addressed. This study shows Cerament G with surgery/systemic antibiotics provides a 97.4% success rate. Therapeutic drivers in this field have been determined traditionally by Physicians and Vascular Surgeons (resection rather than reconstructive surgery.) Our assertion is that eradicating infection in a functionally useless foot is a waste of health resources. Our strategy is always the delivery of an intact functional foot residuum. Cerament G as an adjunct allows this goal in a cost-effective manner

Objectives. Open fracture classification systems are limited in their use. Our objective was to classify open tibia and femur fractures using the OTS classification system in a region with high incidence of gunshot fractures. One hundred and thirty-seven patients with diaphyseal tibia and femur open fractures were identified from a prospectively collected cohort of patients. This database contained all cases (closed and open fractures) of tibial and femoral intramedullary nailed patients older than 18 years old during the period of September 2017 to May 2021. Exclusion criteria included closed fractures, non-viable limbs, open fractures > 48 hours to first surgical debridement and patients unable to follow up over a period of 12 months (a total of 24). Open fractures captured and classified in the HOST study using the Gustilo-Anderson classification, were reviewed and reclassified using the OTS open fracture classification system, analysing gunshot fractures in particular. Ninety percent were males with a mean age of 34. Most common mechanism was civilian gunshot wounds (gsw) in 54.7% of cases. In 52.6% of cases soft tissue management was healing via secondary intention, these not encompassed in the classification. Fracture classification was OTS Simple in 23.4%, Complex B in 24.1% and 52.6% of cases unclassified. The OTS classification system was not comprehensive in the classification of open tibia and femur fractures in a setting of high incidence of gunshot fractures. An amendment has been proposed to alter acute management to appropriate wound care and to subcategorise Simple into A and B subdivisions; no soft tissue intervention and primary closure respectively. This will render the OTS classification system more inclusive to all open fractures of all causes with the potential to better guide patient care and clinical research

Aim. To report outcomes of soft tissue reconstruction using free tissue transfer for the treatment of tibial osteomyelitis as part of a single-stage, ortho-plastic procedure. Method. Patients who underwent ortho-plastic reconstructive surgery to excise tibial osteomyelitis in combination with free tissue transfer in one stage were included. Patients underwent surgery between 2015 and 2024 in a single specialist centre within the UK. Baseline patient information, demographics, and infection information was recorded. Adverse outcomes were defined as (i) flap salvage required, (ii) flap failure and (iii) recurrence of infection. Patient reported quality of life was measured using the EuroQol EQ-5D-5L index score. Pre-operative QoL was compared to QoL at 1 year with a control group of 53 similar patients who underwent surgical treatment for tibial osteomyelitis without a free flap (local flap or primary closure). Results. Ninety-three patients were eligible for inclusion, with a mean age of 52 years (range 18–90). 77/93 (82.8%) had a free muscle flap with the remainder (17.2%) receiving a fasciocutaneous flap. The donor tissue was defined as 57 gracilis, 6 latissimus dorsi, 14 hemi-latissimus dorsi, and 16 anterolateral thigh. The recipient area of the tibia was distal 1/3 in 52 cases, middle 1/3 in 27 cases and proximal 1/3 in 12 cases. The average flap ischaemic time was 70 minutes (range 28 to 125). Seven patients (7.5%) required urgent flap salvage at a median time of 1.0 day (range 0.5 – 4.0). Of these, 4 (4.3%) went on to have total flap failure, of which 2 patients underwent below knee amputation subsequently. Flap failure was due to either arterial (n=2) or venous (n=2) anastomotic thrombus. There were 3 (3.2%) episodes of confirmed infection recurrence within the first year after the index procedure. EQ-index scores at 1-year post-operatively were significantly improved when compared to pre-operative scores (p=0.008). At 1-year post-operatively, EQ-index scores in patients who underwent free flap was similar compared to local flaps (p=0.410) and in those who underwent primary closure for tibial osteomyelitis (p=0.070). Conclusions. Microsurgical single stage surgery can achieve high flap survival rate (95.7%). Free flaps fail early due to anastomotic thrombus with no late failures seen. Free tissue transfer does not appear to give inferior QoL compared to matched patients with local flaps or direct closure in tibial osteomyelitis

We reviewed retrospectively 45 patients (46 procedures) with bladder exstrophy treated by bilateral oblique pelvic osteotomy in conjunction with genitourinary repair. The operative technique and post-operative management with or without external fixation are described. A total of 21 patients attended a special follow-up clinic and 24 were interviewed by telephone. The mean follow-up time was 57 months (24 to 108). Of the 45 patients, 42 reported no pain or functional disability, although six had a waddling gait and two had marked external rotation of the hip. Complications included three cases of infection and loosening of the external fixator requiring early removal with no deleterious effect. Mid-line closure failed in one neonate managed in plaster. This patient underwent a successful revision procedure several months later using repeat osteotomies and external fixation. The percentage pubic approximation was measured on anteroposterior radiographs pre-operatively, post-operatively and at final follow-up. The mean approximation was 37% (12% to 76%). It varied markedly with age and was better when external fixation was used. The wide range reflects the inability of the anterior segment to develop naturally in spite of close approximation at operation. We conclude that bilateral oblique pelvic osteotomy with or without external fixation is useful in the management of difficult primary closure in bladder exstrophy, failed primary closure and secondary reconstruction

Aims. Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Methods. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30). Results. Overall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union. Conclusion. Our multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications. Cite this article: Bone Jt Open 2023;4(7):516–522

Aims. Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. Patients and Methods. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. Results. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. . Conclusion. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53

Aims. Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up. Methods. A total of 84 patients, with a mean age of 68 years (36 to 92), underwent single-stage revision TKA for confirmed PJI at a single institution between 2006 and 2016. In all, 37 patients (44%) were treated for an infected primary TKA, while the majority presented with infected revisions: 31 had undergone one previous revision (36.9%) and 16 had multiple prior revisions (19.1%). Contraindications to single-stage exchange included systemic sepsis, extensive bone or soft-tissue loss, extensor mechanism failure, or if primary wound closure was unlikely to be achievable. Patients were not excluded for culture-negative PJI or the presence of a sinus. Results. Overall, 76 patients (90.5%) were infection-free at a mean follow-up of seven years, with eight reinfections (9.5%). Culture-negative PJI was not associated with a higher reinfection rate (p = 0.343). However, there was a significantly higher rate of recurrence in patients with polymicrobial infections (p = 0.003). The mean Oxford Knee Score (OKS) improved from 18.7 (SD 8.7) preoperatively to 33.8 (SD 9.7) at six months postoperatively (p < 0.001). The Kaplan-Meier implant survival rate for all causes of reoperation, including reinfection and aseptic failure, was 95.2% at one year (95% confidence interval (CI) 87.7 to 98.2), 83.5% at five years (95% CI 73.2 to 90.3), and 78.9% at 12 years (95% CI 66.8 to 87.2). Conclusion. One-stage exchange, using a strict debridement protocol and multidisciplinary input, is an effective treatment option for the infected TKA. This is the largest single-surgeon series of consecutive cases reported to date, with broad inclusion criteria. Cite this article: Bone Jt Open 2021;2(5):305–313

Of 110 consecutive open tibial fractures 90 were reviewed and analysed retrospectively with particular reference to wound closure, method of stabilisation, infection rate and the incidence of non-union. There were 41% Gustilo type I, 39% type II and 20% type III injuries. The incidence of deep infection was 20% after primary wound closure compared with 3% after delayed closure, and eight of the nine non-unions followed primary closure. We conclude that primary wound closure should be avoided in the treatment of open tibial fractures

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure