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. 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

Aim. The primary aim of multidisciplinary management of diabetic foot disease is limb savage. Difficulty in eradication of infection with systemic antibiotics and obliteration of dead space created by debridement, are two major stumbling blocks in achieving this. Antibiotic loaded bio composites help achieve both these objectives. The aim of this study is to report the early results of antibiotic loaded bio composites in diabetic foot disease. Method. We present early results of 16 patients with diabetic foot disease and osteomyelitis in whom we used antibiotic loaded bio composite (CERAMENT G Bone Support, Lund, Sweden) for local antibiotic delivery and dead space eradication. A multidisciplinary team managed all patients. We performed magnetic resonance and vascular imaging preoperatively and adhered to a strict protocol involving debridement, culture specific systemic antibiotics and dead space obliteration with antibiotic loaded bio composite. The wound was managed with negative pressure wound therapy and all patients were kept non-weight bearing with a plaster back slab or walking boot. Skin cover where required was undertaken by our plastic surgeons. Results. According to the Cierny –Mader Classification 1 patient was type 1, 4 were defined as type 2, 7 were type 3 and 4 were type 4. Seven patients were classed as type B hosts and 9 were type A hosts. At a mean follow up of 38 weeks (26–60) we achieved infection clearance in 14 patients (88%). 10 (63%)wounds healed by secondary intention, 2 had split skin graft, and 1 had primary closure. 2 patients were still on negative pressure wound therapy at final follow-up, one of which has got clearance of infection. One patient is having regular dressings in the community. We had 2 patients who had below knee amputation, one due to significant vascular disease and the other at patient request. Conclusions. A multidisciplinary approach and a strict protocol including augmented debridement and Cerament G injection are effective for treatment of chronic osteomyelitis in diabetic foot disease. The early results with this bio composite antibiotic combination are encouraging

Aim. The optimal surgical approach for patients hospitalized for moderate to severe septic bursitis is not known, and there have been no randomized trials of a one-stage compared with a two-stage (i.e., bursectomy, followed by closure in a second procedure) approach. Thus, we performed a prospective, non-blinded, randomized study of adult patients hospitalized for an open bursectomy. Method. Patients were randomized 1:1 to a one-stage vs. a two-stage surgical approach. All patients received postsurgical oral antibiotic therapy for 7 days. These are the final results of the prospective study registered at ClinicalTrials (NCT01406652). Results. Among 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was one-stage in 79 and two-stage in 85. The two groups were balanced with regards to sex, age, causative pathogens, levels of serum inflammatory markers, co-morbidities, and cause of bursitis. Overall, there were 22 treatment failures: 8/79 (10%) in the one-stage arm and 14/85 (16%) in the two-stage arm (Pearson-χ2-test; p=0.23). Recurrent infection was caused by the same pathogen a total of 7 patients (4%), and by a different pathogen in 5 episodes (3%). The incidence of infection recurrence was not significantly different between those in the one- vs. two-stage arms (6/79 vs. 8/85; χ2-test: p=0.68). In contrast, outcomes were better in the one- vs. two-stage arm for wound dehiscence (2/79[3%] vs. 10/85[12%]; p=0.02), median length of hospital stay (4.5 vs. 6 days), nurses’ workload (605 vs. 1055 points) and total costs (6,881 vs. 11,178 Swiss francs) (all p<0.01). Conclusions. For adult patients with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with 7 days of systemic antibiotic therapy, was safe, resource-saving and effective. Using a two-stage approach did not reduce the risk of infectious recurrence, and may be associated with a higher rate of wound dehiscence than the one-stage approach

Introduction. Recent literature has shown increasing interest in analysing return to theatre (RTT) as a quality indicator across different surgical specialities. The aim of this study is to express “RTT at 90 days” as a useful predictor in identifying complications following primary total knee replacement (TKR). Methods. Patients who had been to theatre within 90 days of primary TKR were identified and their clinical notes were reviewed. Patients’ co morbidities, surgeon's grade, details of revision procedures and their final outcome were analysed. Results. Between 2010 and 2012 a total of 1388 primary TKR were performed. Eleven patients, 11/1388 (0.79%) RTT within 90 days, mean age was 71 years (51 to 85), mean body mass index (BMI) was 30.7 (21 to 45). Out of these 11 patients, six had Manipulation Under Anaesthesia (MUA) for stiffness, two had wound exploration and primary closure and three patients underwent revision arthroplasty following failed salvage procedures. Conclusion. Using RTT as a quality marker, it is possible to assess performance of surgeons and institutions much quicker than with joint registry. Our results showed that RTT at 90 days for TKR in our institution is significantly lower than national average (0.79% versus 1.8%)

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Treatment of osteomyelitis is a challenge for every surgeon, but even more so in low and middle income countries, because of delay in presentation, lack of resources and troublesome follow-up. We present a series of fifteen patients, treated for osteomyelitis in 2014 in a rural Ghanean hospital with one-year follow up. All bony defects were filled using Bonalive®. Fifteen consecutive patients with osteomyelitis were included in this study and treated with Bonalive® in March 2014. The group consisted of twelve men and three women (age 10–46y, mean 26y). All patients consented and the study was approved by the hospital's ethical committee. Imaging was performed preoperatively, immediate postoperatively and at various occasions thereafter with final X-rays taken at follow-up in April 2015. All were treated by extensive debridement of the osteomyelitic bone, sequestrectomy, saucerisation and filling of the defect with Bonalive® granules (1,0–2,0 mm in size). Primary closure of the wound was possible in all cases. Fistulae were curetted, not closed. Peroperatively, multiple culture specimens were taken and all patients received a course of intravenous antibiotics for a week, continued orally thereafter for another week. Patients were regularly followed up postoperatively and final review took place in April 2015. Of all fifteen treated patients, only seven were seen back in April 2015, more than one year postoperatively. The osteomyelitis was located in the femur in seven patients, tibia in seven and the humerus in two. Microbiology showed growth of St. aureus in six patients, Proteus species in six, St. epidermidis in two and pseudomonas in one. Of the seven patients presenting at one year follow-up, all had relief of symptoms for at least three months. Two were completely symptom free, the other five still had one or more draining fistulae. Initial X-rays showed good filling of all osteomyelitic defects with the bioglas granules. Treatment of osteomyelitis remains a challenge in low and middle income countries. First, there is almost always a delay in presentation and most cases have become chronic by the time they are treated. Secondly, some sequesters were missed and therefore not removed at surgery, due to the lack of good initial x-ray films. Thirdly, there is often no access to microbiological diagnostics. At last, a lot of patients are lost to follow-up. In our opinion, the Bonalive® product delivered it's claims, but the overall circumstances in which we treated these patients were importantly responsible for the overall suboptimal outcome

Gold standard for the management of non-union is open surgical debridement, stabilisation, and autologous bone grafting. LIPUS is becoming more popular, yet the evidence is still inconclusive. LIPUS involves the use of ultrasound at the fracture site with little risk to the patient. The purpose of this study was to assess effectiveness and cost benefit of LIPUS in the management of non-unions post sustaining an open fracture. We retrospectively reviewed 29 patients with open fractures with established non-union undergoing LIPUS since 2010 (4 females, mean age 48) range 3–27 months, mean 9 months, either post injury or last intervention. All were tertiary referrals, sustaining injuries to the following areas; Tibial 21, Femur 6, Humerus 2, Radius 1. Definitive fixation being; 9 TSF's, 11 IMN's, 9 plates. (undergoing a mean 2.4 procedures). Aside from sustaining an open fracture, 7 had risk factors for non-unions 5 smokers, 2 NSAID's. Failure of treatment was based on undertaking bone grafting. In 28 patients (1 lost to follow up) union was achieved in 71% (mean 157 days). All were screened for infection, 4 had organisms on enrichment culture. 8 (5 Gustillo Anderson Grade 3A/B) injuries did not show evidence of callus formation, LIPUS was discontinued and grafting performed. Open fractures were graded as; 7 Grade 1, 4 Grade 2, 8 Grade 3A, 10 Grade 3B being received. Of these; 20 underwent primary closure, 6 free flaps and 3 SSG. The cost of LIPUS is approx £2500, compared bone grafting using autologous iliac crest graft with no medical comorbidities of £3715. This case series further supports union rates after LIPUS. Cost and morbidity benefit of utilising LIPUS over opting for bone grafting initially is £1215 per patient. Whilst autologous bone grafting is currently the gold standard, it is not without morbidity. We achieved union rates of 71% despite a number of patients having recognised risk factors, showing that LIPUS is a useful resource in the management of non-union

The operative workload at the surgical facility in Camp Bastion, Afghanistan, has previously been reported for the two-year period 1 May 2006 to 1 May 2008. The nature of the Afghanistan conflict has changed considerably since 2007, and wounds from improvised explosive devices (IEDs) have replaced those of small arms fire as the signature injury of the insurgency. The severity of injury from IEDs has increased such that casualties routinely present with high bilateral traumatic lower limb amputations and associated pelvic, perineal, upper limb and facial wounds. These complex injuries affecting multiple anatomical zones necessitate a multi-surgeon team approach in their management. We present recent data for the surgical activity at the JF Med Gp Role 3 Hospital, Camp Bastion, for the two-year period 1 November 2008 to 1 November 2010. During the study period, a total of 4276 cases required 5737 surgical procedures, representing a 2.6-fold increase in activity compared with the previously reported 2-year period. Of these cases, 42% were coalition troops (ISAF) and 6% children. Wound debridement (44%) and relook/delayed primary closure of wounds (10%) remain the most commonly performed procedures. There has been a marked increase in the rates of amputation (8% of procedures, 48% being above-knee), laparotomy (9%), application of external fixation (4.5%), and fasciotomies (3%). Scrotal exploration accounted for 1.9% of procedures, resulting in 17 orchidectomies. During the 2-year study period, we have also observed a considerable increase in the incidence of cases requiring 5 or more surgeons operating simultaneously

Previous reports have shown the efficacy of muscle interposition grafts in treating recalcitrant infection in the presence of hip arthroplasty. We report our experience with a two stage debridement and rectus femoris pedicled interposition graft technique in chronic severe native hip infection with a persistent draining sinus. During the last 16 months, three paraplegic patients presented with persistently draining sinuses and chronic osteomyelitis of the pelvis, acetabulum and proximal femur, in a total of four hips. The mean patient age was 49 years (range, 40 to 59 years). In all patients there had been previous attempts to control the infection with wound debridement and long-term antibiotics. A two-stage operative treatment was used in all patients. The first stage comprised wound debridement, washout, gentamycin-bead application and temporary vacuum assisted wound coverage. At the second stage, approximately ten days later, through a standard anterior midline incision, the rectus femoris muscle was elevated on its pedicle, rolled, transposed into the acetabulum and sutured to the transverse acetabular ligament. At the second stage, all patients had local administration of antibiotics with genetamycin impregnated absorbable collagen fleece and all wounds were closed by delayed primary closure with a negative pressure dressing placed over the closed wound. All patients were commenced on a 6 week course of intravenous antibiotics, according to sensitivities. No loss of flap occurred in any of the patients. One wound had partial dehiscence and required a split skin graft. At the final follow-up examination all the wounds were healed and there was no recurrence of draining sinuses, pressure sores or systemic sepsis. The two stage technique with a pedicled rectus femoris interposition graft may be a useful technique for the treatment of complex chronic persistent osteomyelitis of the pelvis, acetabulum and proximal femur, with the primary aim of stopping the discharging sinus

Massive segmental bone defects in long bones remain a considerable clinical challenge and are a source for significant morbidity and prolonged dysfunction for the patient. We demonstrate the successful use of resorbable polylactide membranes as a scaffold for autologous bone graft in the treatment of a 10cm traumatic femoral bone defect. A 28-year-old male was involved in a motorcycle accident vs. tree at 140k/hr. He sustained a Gustillo grade 3b intercondylar fracture of his right femur, and a 10cm piece of his femoral bone found at the scene was brought to Emergency in a sterile container. He was taken to theatre for debridement and ORIF of the intercondylar fracture, with vacuum dressing cover. Day 5 post injury the patient returned to theatre and the LISS plate was revised to correct the rotation and 3cm shortening. The 10cm cortical defect now present was filled with antibiotic cement (Palacos) and delayed primary closure was performed. Day 21 post injury the cement spacer was removed and replaced with two polylactide membrane tubes, one within the medullary canal and the other around the outside of the bone. The “neocortical” space thus produced was grafted with cancellous autograft mixed with bone morphogenic protein (OP1, Stryker). The remainder of the post-operative course was uncomplicated and the patient was discharged home 5 days later. The patient was reviewed at the 6 week and 3 month mark post injury. The femoral defect demonstrated both radiological and clinical union at the 3 month mark and full weight bearing was permitted. His range of motion at that stage was 5 to 95 degrees with no sign of infection. The use of polylactide membranes as a scaffold in the treatment of segmental long bone defects is an excellent and relatively straightforward technique. Forming a space between the 2 tubes controls cancellous graft to the site of the cortical area where it is required and the polylactide membrane then resorbs over years producing CO2 and water. This case demonstrates that the use of polylactide membranes is safe and effective in the management of segmental long bone defects

On 7 July 2005, four bombs were detonated on the London transport system. Three of these bombs exploded almost simultaneously at 08:50h affecting the underground tube network at Aldgate, King's Cross and Edgware Road stations. The fourth bomb exploded at 09:47h on a double-decker bus in Tavistock Square. There were 54 deaths in total at the scenes and over 700 injured. 194 patients were brought to the Royal London Hospital. 167 were assessed in a designated minor injuries unit and discharged on the same day. 27 patients were admitted of whom 7 required ITU care, 1 died in theatre and 1 died post-operatively. The median Injurity Severity Score (ISS) in this group of patients was 6 (range 0-48) and the mean ISS was 12. The general pattern of injury in the critically ill patients was of mangled lower limbs and multiple, severely contaminated fragment wounds. Hepatitis B prophylaxis was administered to those patients with wounds contaminated by foreign biological material. 11 primary limb amputations were performed in 7 patients. 9 limb fasciotomies, 5 laparotomies and 1 sternotomy were carried out. 3 patients had blast lung injury. All patients who underwent primary amputations and debridement received further regular inspections in theatre. These inspections formed the majority of our theatre work. Under no circumstance was initial reconstructive surgery attempted. Delayed primary closure and split skin grafting of all wounds was completed by the end of the second week. There have been no sepsis-related deaths. Our experience at The Royal London has allowed us to revisit the principles of blast wound management in a peacetime setting. A number of lessons were learned regarding communication and resource allocation. A multi-disciplinary approach with the successful execution of a major incident plan is the key to managing an event of this magnitude

Unstable fractures of the distal tibia are being increasingly treated by open reduction and internal fixation using pre-contoured locking plates. Functional outcome following this type of fixation has not been reported previously. The aim of this study was to functionally assess patients following MIPO fixation of distal tibial fractures. Case notes of 26 patients treated at a single centre were reviewed. The fracture type, fixation technique, complications, time to union and subsequent treatment were documented. All patients returned for functional scoring using the validated American Academy of Orthopedic Surgeons (AAOS) foot and ankle core score. Twenty-six consecutive patients were treated between 2002-2005. The majority were male, and 5 were open fractures. There were 13 AO type A, 4 type B and 9 type C fractures. Mean follow up was 20 months. Average time from injury to surgery was 2.5 days. All fractures were treated by a MIPO technique. A pre-contoured distal locking plate was used for the distal tibial reconstruction. Secondary surgical procedures e.g. 2nd look, delayed primary closure, or skin grafting were necessary in 3 cases. The fibula was plated in 60% of cases. Four patients developed wound infections requiring antibiotics, and all resolved. The commonest rehabilitation regime was 6 weeks non weight bearing in plaster. Mean time to union was 18 weeks. There were 3 cases of delayed union, requiring bone grafting. One patient required removal of the plate due to local irritation, and one required a broken screw to be removed. Mean range of movement was 10 degrees dorsiflexion, 30 plantarflexion. The mean normalised AAOS foot and ankle core score was 41 (SD +/− 8). We conclude that MIPO fixation of distal tibial fractures is a safe and effective method of treatment. Functional outcome does not significantly differ from that of the general population

The method of choice in the management of chronic infections is the exchange arthroplasty. The exchange arthroplasty can be performed either in a one- or in a two-stage setting, whereas the two-stage exchange arthroplasty is still considered the “gold standard” worldwide. The current literature and guidelines for PJI treatment deliver no clear evidence that a two-stage exchange procedure has a clearly higher success rate than the one-stage procedure. Since the first implantation of mixing antibiotics into bone cement in 1970s, the ENDO-Klinik followed until today in over 85% of all infected cases the one-stage exchange arthroplasty for the management of PJI. The main requirement is the known germ with known susceptibility based on microbiological diagnostics. Proper bone stock for cemented, in some cases, uncemented reconstruction, and the possibility of primary wound closure are also clear assumptions. The one-stage exchange arthroplasty delivers diverse advantages. For instance, the need for only one operation, shorter hospitalization, reduced systemic antibiotics and lower overall cost. A well-defined pre-operative planning regime is absolutely mandatory

Since its approval by the FDA two decades ago, Negative Pressure Wound Therapy (NPWT) has become a valuable asset in the management of open fractures with significant soft tissue damage as those seen in high velocity gunshot injuries. These lesions are often associated with grossly contaminated wounds and require a prompt and effective approach. Wound dehiscence and surgical site infection are two of the most common post-operative complications, with poor results when treated with standard gauze dresses. NPTW comes as a legitimate resource promoting secondary intention healing through increased granulation and improved tissue perfusion, as well as continuous local wound drainage preventing bacterial growth and further infection. Recent evidence-based guidelines are still limited for use of NPWT in the treatment of Gustilo-Anderson type IIIB open fractures and there are few cases in literature reporting the management of upper extremity injuries. We present and discuss a successful case of a type IIIB open humeral fracture wound treated with NPWT. A 38-years-old male was admitted to the Emergency Room with a type IIIB open humeral fracture as a result of a gunshot with extensive soft tissue damage. IV antibiotic therapy was promptly started followed by surgical stabilization by intramedullary nailing with primary wound closure. The patient presented an early surgical site infection with wound dehiscence requiring secondary debridement with poor subsequent healing and deficient soft tissue coverage. After ineffective 28 days of standard gauze dresses we started NPWT. NPTW was applied using foam coverage over the dehiscence area with visible results after 13 days and complete granulation of the skin defect by the 28th day. The wound healed completely after 14 weeks of NPWT. The fracture evolved into a painless pseudarthrosis revealing an excellent functional recovery and an acceptable aesthetic result. NPTW is a valuable, effective, and well tolerated resource in the treatment of open fractures with extensive soft tissue damage such as Gustilo-Anderson type IIIB fractures. It should be considered not just as a salvage procedure but as well as a primary option especially in grossly contaminated wounds. No benefits in any form have been received from a commercial party

UK Objective. To evaluate the technique of transverse debridement, acute shortening and subsequent distraction histiogenesis in the management of open tibial fractures with bone and soft tissue loss thus avoiding the need for flap coverage. Methods. We present a retrospective review of 18 patients with Gustillo grade III open tibial fractures between 2006 and 2011. Initially managed with debridement to provide bony apposition through transverse wound excision. This allowed primary wound closure without tension, or mobilization of local muscle followed by split skin graft to provide cover. Temporary mono-lateral external fixation was utilized to allow soft tissue resuscitation, followed by Ilizarov frame for definitive fracture stabilization. In some cases it was possible to apply an Ilizarov frame at the time of initial debridement. Leg length discrepancy was subsequently corrected by corticotomy and distraction histiogenesis. Union was evaluated radiologically and clinically. Results. Mean age 36.4 years (18.4–59.2 years). Mean bone defect 3.5 cm (0.5–10 cm). Mean soft tissue defect 4.1 cm (1.8–10 cm). Mean follow up was 81 weeks (30–174 weeks). 16 fractures united, with a mean time to union of 38 weeks (24–79 weeks). There was one hypertrophic nonunion which united after a second frame. One patient was lost to follow up before fracture union. Three patients had pin site infections, two of which required intravenous antibiotics. One patient developed chronic osteomyelitis but manages with a discharging sinus. There were no amputations. Conclusion. Acute shortening followed by distraction histiogenesis is a safe method for the treatment of severe open tibial fractures with bone and soft tissue loss. The technique also avoids the morbidity, cost and logistical issues associated with the use of local or free tissue flaps

Bactericidal levels of antibiotics are difficult to achieve in infected total joint arthroplasty when intravenous antibiotics or antibiotic-loaded cement spacers are used, but intra-articular (IA) delivery of antibiotics has been effective in several studies. This paper describes a protocol for IA delivery of antibiotics in infected knee arthroplasty, and summarises the results of a pharmacokinetic study and two clinical follow-up studies of especially difficult groups: methicillin-resistant Staphylococcus aureus and failed two-stage revision. In the pharmacokinetic study, the mean synovial vancomycin peak level was 9242 (3956 to 32 150; sd 7608 μg/mL) among the 11 patients studied. Serum trough level ranged from 4.2 to 25.2 μg/mL (mean, 12.3 μg/mL; average of 9.6% of the joint trough value), which exceeded minimal inhibitory concentration. The success rate exceeded 95% in the two clinical groups. IA delivery of antibiotics is shown to be safe and effective, and is now the first option for treatment of infected total joint arthroplasty in our institution.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):31–6.