Purpose: Management of septic nonunion of long bones is a difficult challenge requiring a multidisciplinary approach. The purpose of this study was to report our results with a two-stage technique using a spacer (Masquelet technique). Material and methods: Between June 1997 and July 2001, eleven patients were treated for septic nonunion (n=7) or suspected septic nonunion (n= =4). There were seven men and four women: mean age 38 years (26–51). Nonunion involved the humerus (n=1), the femur (n=1), and the tibia (n=9). The same surgical technique was used in all cases: “carcinologic” debridement with gap filling using antibiotic cement and osteosynthesis when necessary, followed by a second procedure two months later to remove the spacer and insert an autologous bone graft when laboratory results had returned to normal. Results: Mean follow-up was three years (1–5). All patients achieved per primam bone healing within 4.5 months (3–6) despite a mean bone gap of 55 mm (15–100) after avivement. Intraoperative samples taken during the second procedure were negative and there was no recurrent infection or need for revision. Discussion: This two-phase technique has provided encouraging results in terms of “infectious cure” and bone healing. A standardised approach to the treatment of septic nonunion of long bones as used in our centre should provide data validating this technique

Purpose: The diversity of treatments proposed for septic nonunion of the femur demonstrates the lack of consensus. Treatment modalities validated for the leg appear to be transposable to the femur. The purpose of this work was to compare different treatments used in our centre and identify optimal management practices. Material and methods: We report a retrospective series of eleven patients (nine men and two women) who developed septic nonunion of the femur subsequent to trauma (n=9) or tumour (n=2). Sepsis developed early in seven cases and late in four. Mean time to treatment was 34.8 months. We based our strategy on a succession of steps starting with cure of the soft tissue and bone infection, before attempting reconstruction and consolidation.The first step involved fixation, antibiotic therapy and interposition of an acrylic spacer. The second step involved bone reconstruction, removal of the spacer, vascularised fibular graft associated with a cancellous bone graft (n=4) or massive cancellous graft inserted into the pseudomembrane created by the spacer (n=7). Results: Mean time to resolution of the infection was 10.9 months. Cure could not be achieved in three patients. Bone continuity was achieved in 8.8 months on average. The time to bone healing (i.e. duration of external fixation) was 22 months. Refracture occurred in four patients. Consolidation was not achieved in two patients. Discussion: During the second step, we preferred massive cancellous bone reconstruction due to easier technique, shorter healing time, and better adaptation of the reconstruction volume. Optimal time for the first step is about six months in order to avoid recurrent infection. Our healing times are similar to those reported by others: the healing index (time to healing divided by gap length) was close to that obtained with the compression-distraction technique. Refractures related to specific mechanical problems inherent in the femur lead to longer time for external fixation, minimum 13 months

Purpose: The purpose of this study was to evaluate the results of 23 patients with septic nonunion of the distal tibial metaphysis type Pilon fractures treated with Ilizarov technique. Material and Methods: Between 1990 and 2002 the Ilizarov technique was used in 23 patients with posttraumatic infected nonunion of the distal tibia. Seventeen were males and 6 females. Average age was 40.1 years (range16–68 years). Mean duration of nonunion was 13,8 months and the average number of failed previous surgical procedures 2.2. According to AO classification there were 3 non-unions with quiescent infection and no drainage, 4 with active infection and no drainage, and 16 with infection and drainage. The ankle joint was ankylosed in 6 patients preoperatively and it was painful in all patients. Thirteen patients had an angular deformity of more than 7 degrees (range 7–30 degrees, mean 16 degrees). Sixteen patients had a mean bone defect of 2.5 cm (range 1 to 6 cm). Monofocal or bifocal compression-distraction osteogenesis technique with or without bridging the ankle joint was performed in all cases. Ankle arthrodesis was necessary in 4 cases. Mean external fixation time was 139.6 days and mean follow-up period was 4 years. Results: The results were evaluated using the functional and radiological scoring system described by Paley. The results were excellent in 7 patients (30.4%) good in 9 (39.1%) fair in 5 (21.7%) and 2 (8.69%) poor while the functional results were excellent in 4 patients (17.39%) good in 8 (34,8%), fair in 7 (30,4%) and poor in 4 (17,39%). Bone union and eradication of infection were achieved in all cases. Four bone defects required bone grafting and freshening at the docking site. Ankle motion was difficult to record preoperatively but good to very good ankle function was obtained at final follow up evaluation in 12 patients. Conclusions: The Ilizarov technique is a reliable method in the treatment of metaphyseal septic nonunion of the distal tibia particularly in cases with angular deformity, ankle joint contracture and bone defects. Compliance of the patient is absolutely necessary

Purpose of the study: There are several goals for the treatment of septic nonunion of the leg: control the infection, achieve healing, preserve function. The purpose of this work was to report the results obtained with a two-phase technique using a cement spacer. Material and method: From 1994 to 2007, 27 patients were treated for a septic nonunion of the tibia (19 proven, 8 suspected). There were 22 women and 5 men, mean age 39 years (range 16–66). The first phase of the surgical technique involved “cancerological” cleaning and insertion of an antibiotic cement spacer. Osteosynthesis was performed if necessary. Antibiotics were adapted to sample results. The second phase involved an autologous bone graft with osteosynthesis after biological markers had returned to normal and an antibiotic window. Antibiotics were then discontinued if samples were negative. Patients were reviewed with physical examination, radiology, and laboratory tests at one year. Results: Mean follow-up was 4 years (range 1–11). At the first phase, mean bone defect after cleaning was 5 cm (range 3–8); osteosynthesis procedures were required for 22 patients (81.5%), mainly with plate fixation. Mean time to the second phase was 4 months (range 1.5–22). At the second phase, bone loss was filled with isolated bone fragments (44%) or associated with a tricortical graft (52%) or a plate nail combination (37%). Bacteriological samples were negative for 25 patients after the second phase. Six patients required surgical revision for recurrent aseptic non-union (22%). Discussion: All patients healed at mean one year with a tolerable misalignment in 37%. At last follow-up there were no cases of infection. Nineteen patients had residual stiffness of the ankle or knee but 80% had resumed their sports activities and 85% their occupational activities. Conclusion: A two-phase surgical treatment of septic non-union of the leg is effective. We were able o achieve cure of the infection in all patients with per primam healing in 78% in addition to an acceptable functional outcome. The spacer offers the advantage of preparing a bed for the graft and preserving autonomy between the two phases

Aims. The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition. Methods. A cohort of 106 patients having surgery for suspected septic nonunion after failed fracture fixation were studied. Blood samples were collected preoperatively, and the concentration of serum CRP, WBC, and differential cell count were analyzed. The areas under the curve (AUCs) of diagnostic tests were compared using the z-test. Regression trees were constructed and internally cross-validated to derive a simple diagnostic decision tree. Results. Using the FRI consensus definition, 46 patients (43%) were identified as infected. Sensitivity, specificity, and AUC of CRP were 67% (95% confidence interval (CI) 52% to 80%), 61% (95% CI 47% to 74%), and 0.64 (95% CI 0.54 to 0.74); of WBC count were 17% (95% CI 9% to 31%), 95% (95% CI 86% to 99%), and 0.57 (95% CI 0.50 to 0.62); of %N 13% (95% CI 6% to 26%), 87% (95% CI 76% to 93%), and 0.50 (95% CI 0.43 to 0.56); and of NLR 28% (95% CI 17% to 43%), 80% (95% CI 68% to 88%), and 0.54 (95% CI 0.46 to 0.63), respectively. A better performance of serum CRP was shown in comparison to the leucocyte count (p = 0.006), %N (p < 0.001), and NLR (p = 0.001). A statistically lower serum CRP level was shown in patients with an infection caused by a low virulence microorganism in comparison to high virulence bacteria (p = 0.008). We found that a simple decision tree approach using only low serum neutrophils (< 3.615 × 10. 9. /l) and low CRP (< 2.45 mg/l) may allow better identification of aseptic cases. Conclusion. The evaluated serum inflammatory markers showed limited diagnostic value in the preoperative diagnosis of FRI when using the uniform FRI Consensus Definition. Therefore, they should remain as suggestive criteria in diagnosing FRI. Although CRP showed a higher performance in comparison to the other serum markers, it is insufficiently accurate to diagnose a septic nonunion, especially when caused by low virulence microorganisms. Cite this article: Bone Joint J 2020;102-B(7):904–911

The clinical case refers to a male patient, 34 years old, admitted at the Emergency Department after a fall of 2 meters. Of that trauma, resulted an exposed Monteggia fracture type III – Gustillo & Anderson IIA – on his left arm.

With this work, the authors intend to describe the evolution of the patient's clinical condition, as well as the surgical procedures he was submitted to.

The authors used the patient's records from Hospital's archives, namely from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution.

The clinical case began in December 2011, when the patient suffered a fall of 2 meters in his workplace. From the evaluation in the Emergency Department, it was concluded that the patient presented, at the left forearm, an exposed Monteggia type III fracture – Gustillo & Anderson IIA – combined with a comminuted fracture of the radial head. At the admission day, the wound site was thoroughly rinsed, the fracture was reduced and immobilized with an above-the-elbow cast, and antibiotics were initiated. Six days after admission, the patient was submitted to open reduction with internal fixation with plate and screws of the fracture of the ulna and radial head arthroplasty. The postoperative period was uneventful. Two months after the surgical procedure, inflammatory signals appeared with purulent secretion in the ulnar suture. Accordingly, the patient was submitted to fistulectomy, rinsing of the surgical site and a cycle of antibiotics with Vancomycin, directed to the S. aureus isolated from the purulent secretion. The clinical evolution was unfavorable, leading to the appearance of a metaphyseal pseudarthrosis or the ulna and dislocation of the radial head prosthesis. The previously implanted material was therefore removed, 4 months after the traumatic event; at the same time an external fixation device was applied and the first part of a Masquelet Technique was conducted. The second part of the aforementioned procedure was carried out in December 2012. The patient was discharged from the consultation after a 2 years follow-up, with a range of motion of the left elbow acceptable for his daily living activities.

In spite of the multiple surgical rinsing procedures and directed antibiotics, the development of a metaphyseal pseudarthrosis of the ulna was inevitable. This clinical case illustrates how the Masquelet Technique presents itself as a good solution for the cases of non-union of fractures in the context of infection.

Despite the increase of surgical procedures for extremities injuries and improvement of various fixation devices and surgical methods, the number of unsatisfactory osteosynthesis results reaches 2–7%. Chronic osteomyelitis after lower extremities long bones osteosynthesis occurs in 1.3–23% of cases, and the percentage of bone nonunion due to infections reaches 83%.

We conducted a retrospective analysis of 237 patient treatment with chronic osteomyelitis following tibial and femoral bone osteosynthesis. Two groups were selected for the analysis: the first group contained 194 patients treated with sheets and the second one contained 43 patients treated with intramedullary locked nails.

In cases of unconsolidated fractures and false joints, the necrectomy was performed with single-step or two-step replacement of internal fixation for external fixation. In this case segmental bone defects reached 20.9% in the first group and 3.6% in the second one. Here the treatment was performed using the Ilizarov method with the bone defect distraction replacement.

Conclusions. 1. Chronic osteomyelitis following sheets usage, unlike the osteomyelitis following the intramedullary locked osteosynthesis, leads more often to the formation of edge and segmental bone defects, which significantly prolongs the treatment duration.

2. External fixation application for postoperative osteomyelitis treatment in case of the bone nonunion made it possible to eliminate the purulent process and restore the extremity support function.

3. The inflammatory process relapses reached 14.9% in the first group and 3.1% in the second one.

Introduction. Polymicrobial infections are expected to complicate the treatment of bone and joint infections. Septic nonunions often occur after initial open fractures, which prophylactically receive broad-spectrum antibiotics. However, no data that describes frequencies of polymicrobial infections and pathogens evident in course of the treatment of septic nonunions is published. Therefore, this study aims at investigating the frequency and pathogen types in polymicrobial infections. Methods. Surgically treated Patients with long bone septic nonunion admitted between January 2010 and March 2018 were included in the study. Following parameters were examined: age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and anatomical location of the infected nonunion. Microbiological culture data, polymerase-chain-reaction results of tissue samples, sonication, and joint fluid of the initial and follow-up revision surgeries were assessed. No exclusion criteria were determined. Results. The study encompassed 42 patients with a mean age of 53.9 ± 17.7 years (range, 23 – 93). Sixteen (38.1%) patients were female. In 46.3% of the patients open fractures led to septic nonunion. Twenty-six nonunions occurred at the tibia or fibula, 11 were localized at the femur, 2 at the humerus and 3 at the forearm. Only 2 patients were assessed as ASA type 1, while 26 were ASA type 2 and 12 patients ASA type 3. Mean number of performed surgeries was 6 ± 0.67 (range 2 – 21). In 6 patients (14.3%) polymicrobial infection were evident. A change of evidenced pathogens in course of the treatment occurred in 21 patients (50%). In 16 patients (38.1%) previously detected bacteria could be evidenced by microbial testing after further revision surgery. Staphylococcus aureus was most often evident (n=34, 30.6%), followed by Enterococcus species (n=25, 22.5%) and Staphylococcus epidermidis (n=18, 16.2%). Five Staphylococcus aureus were resistant to methicillin (MRSA). In patients without polymicrobial infection or further germ detection in course of the treatment 86.4% of the infections were due to Staphylococcus species. Patients with change of detected pathogens and polymicrobial infections suffered from more enterococci infections. Infections due to streptococci and gram-negative bacteria could only be evidenced in patients with polymicrobial infection and pathogen change in course of the treatment. Conclusion. The observed difference of microbiological patterns in septic nonunion may help to facilitate adjuvant local and systemic antibiotic treatment in septic nonunion patients. Reasons for the observed difference of microbiological patterns and its influence on patient outcome have still to be elucidated

Aim. Treatment algorithms for fracture-related nonunion depend on the presence or absence of bacterial infection. However, the manifestation of septic nonunion varies. Low-grade infections, unlike manifest infections, lack clinical signs of infection and present similarly to aseptic nonunion. The clinical importance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the clinical relevance of low-grade infection in the development and management of femoral or tibial nonunion. Method. A prospective, multicenter clinical study enrolled patients with nonunion and regular healed fractures. Preoperatively, complete blood count without differential, C-reactive protein (CRP), and procalcitonin were obtained, clinical signs of infection were recorded, and a suspected septic or aseptic diagnosis was made based on history and clinical examination. During surgical nonunion revision or routine implant removal, tissue samples were collected for microbiology and histopathology, and osteosynthesis material for sonication. Nonunion patients were followed for 12 months. Definitive diagnosis of “septic” or “aseptic” nonunion was made according to diagnostic criteria for fracture-related infection, considering the results of any further revision surgery during follow-up. Results. 34 patients with regular healed fractures were included. 62 nonunion patients were diagnosed as aseptic, 22 with manifest, and 23 with low-grade infection. The positive predictive value was 88% and the negative predictive value 72% for the suspected diagnosis. The nonunion groups had significantly higher CRP levels than the regular healer group. Differentiation between septic and aseptic nonunion based on blood values was not possible. Low-grade infection demonstrated less frequently histopathologic signs of infection than manifest infection (22% vs. 50%, p=0.048), with 15% of regular healers having histopathologic signs of infection. Cutibacterium acnes was less present in manifest compared to low-grade infection (p=0.042). Healing rates for septic nonunion involving C. acnes were significantly lower for manifest infection (20%) than for low-grade infection (100%, p=0.002). Patients with low-grade infection were treated with systemic antibiotics less frequently than patients with manifest infection (p=0.026), with no significant difference in healing rate (83% vs. 64%), which was slightly lower for low-grade infection than for aseptic nonunion (90%). Conclusions. Low-grade infections play a significant role in nonunion development and are difficult to diagnose preoperatively due to the lack of clinical signs of infection and unremarkable blood counts. However, our results imply that for low-grade infections, antibiotic therapy may not always be mandatory to heal the nonunion. This study was supported by the German Social Accident Insurance (FF-FR0276)

Aims: To evaluate the effectiveness of the Ilizarov method in treating septic nonunions of lower extremities. Method: Between 1990–2001, 74 patients (59 males and 15 females), with infected nonunion of the tibia and femur were treated using the Ilizarov device (the monofocal or bifocal com-pressiondistraction technique). The average age was 36 years (range 17–68 years) and the patients were evaluated using a modiþed Paley classiþcation for septic nonunions. The mean preoperative bone defect was 9 cm (range 3–18 cm) and it was present in 39 of 74 patients. The mean lengthening index was 36 days/cm (range 27–42 days/cm), the mean external þxation time was 6,3 months (range 3–24 months) and the mean follow up period after frame removal was 4 years (range 1–11 years). Results: Bone union was achieved in all 74 patients (100%) with no infection recurrence. The bone results were excellent in 52 patients (70%), good in 11 (15%), fair in 6 (8%) and poor in 5 (7%), whereas the functional results were excellent in 27 patients (36,5%), good in 35 (47%), fair in 7 (9,5%) and poor in 5 (7%). In four patients bone grafting at the docking site was needed. Late complications included: 9 axial deformities (12,2%), 2 re-fractures (2,7%) and 28 patients (37,8%) with joint stiffness. Conclusions: The Ilizarov technique in the treatment of septic nonunion has a high rate of success considering bone union, bone loss restoration and eradication of infection Sports Ð varia

Aims. This study aimed to investigate the role of quantitative histological analysis in the diagnosis of fracture-related infection (FRI). Patients and Methods. The clinical features, microbiology culture results, and histological analysis in 156 surgically treated nonunions were used to stratify the likelihood of associated infection. There were 64 confirmed infected nonunions (one or more confirmatory criteria: pus, sinus, and bacterial growth in two or more samples), 66 aseptic nonunions (no confirmatory criteria), and 26 possibly infected nonunions (pathogen identified from a single specimen and no confirmatory criteria). The histological inflammatory response was assessed by average neutrophil polymorph (NPs) counts per high-power field (HPF) and compared with the established diagnosis. Results. Assuming a cut-off of over five neutrophils per high-power field to diagnose septic nonunion, there was 80% sensitivity and 100% specificity (accuracy 90%). Using a cut-off of no neutrophils seen in any high-power field to diagnose aseptic nonunion, there was a sensitivity of 85% and a specificity of 98% (accuracy 92%). Conclusion. Histology can be used in a bimodal fashion as a diagnostic test for FRI. The presence of more than five NPs/HPF had a positive predictive value for infected nonunion of 100%, while the complete absence of any NPs is almost always indicative of an aseptic nonunion (positive predictive value of 98%). Cite this article: Bone Joint J 2018;100-B:966–72

The management of upper limb nonunions can be challenging and often with unpredictable outcomes. In the study we present the results of treatment of upper limb nonunions treated in our institution with BMP-7 biological enhancement. Between 2004 and 2011 all consecutive patients who met the inclusion criteria were followed up prospectively. Union was assessed with regular radiological assessment. At the final follow up clinical assessment included the disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement and patient satisfaction. The mean follow up was 12 months (12–36). In total 42 patients met the inclusion criteria with a mean age of 47. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal radius/ulna, 14 humerus, 6 distal radius and 3 clavicles. 5 patients had septic nonunion, 35 had atrophic nonunion, 11 had previous open fractures, and 10 had bone loss (range 1–3 cm). The mean number of operations performed and the mean time from injury to BMP application was 1.5 and 26 months, respectively. 40 patients had both clinical and radiological union whereas 2 had partial radiological union but a pain free range of motion. BMP was applied in isolation in 1 case and 41 cases the application was combined with autologous bone grafting. The range of movement of the affected limb, DASH score and patient satisfaction were optimum at the final follow up. This study supports the use of BMP-7 as a bone stimulating adjunct for the treatment of complex and challenging upper limb nonunions

Introduction:. 20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation. Material and Methods:. 9 cases of long bone defect (humerus and forearm) and 11 cases of bone defect at the hand have been included in this multicentre prospective study (3 centers). The aetiology in 11 cases was trauma, 7 cases were septic nonunions and 2 cases followed tumors. In the hand the bone loss was at least one phalanx, and for long bones the mean defect was 5 cm (3–11). All cases were treated by the induced membrane technique which consists in stable fixation, flap if necessary and in filling the void created by the bone defect by a cement spacer (PMMA). This technique needs a second stage procedure at the 2. nd. month where the cement is removed and the void is filled by cancellous bone. The key point of this induced membrane technique is to respect the foreign body membrane which appeared around the cement spacer and which creates a biologic chamber for the second procedure. Bone union was evaluated prospectively in each case by a surgeon not involved in the treatment, by X-ray and CT scan. Failure was defined as a nonunion at 1 year, or an uncontrolled sepsis at 1 month. Results:. 3 cases failed to achieve bone union, 2 in the hand and 1 in a long bone. No septic complications occurred and all septic cases healed. In 14 cases bone union was achieved with a delay of 5 months (1, 5–12). 2 biopsies allowed us to prove that osteoid tissue was created by the technique. At hand level all fingers have included. At shoulder and elbow level, function reached 75% of motion of the contralateral side. Discussion:. Masquelet first reported 35 cases of large bone defect of tibia nonunion treated by the induced membrane technique which allow filling a bone defect with cancellous bone alone. The cement spacer induces a foreign body membrane (neo periosteum) which constitute a biological chamber. Animal models showed the properties of the membrane: secretion of growths factors (VEGF, TGFbéta1, BMP2) and osteoinductive activitie of the cells. Conclusion:. This technique is useful in emergency or in septic condition where a bone defect cannot be solved by shortening. The technique avoids the use of microsurgery and the limit is the quantity of available cancellous bone

Regardless of the method used, open ankle arthrodesis is known to have a high rate of nonunion, reported to range from 4% to 25%. Salvage of failed ankle fusion is thus a relatively common procedure. Further, in cases of bone loss after distal tibial trauma, necrosis of the talus, Charcot joints and severe deformities of the ankle, there are known to be increased incidences of delayed union and nonunion. Since 1997, 25 salvage ankle arthrodesis procedures have been performed, using a retrograde interlocking intramedullary nail as fixation. In this paper we discuss the indications, surgical techniques and results. At a mean of nine weeks postoperatively, union was achieved in all cases. Complications included one case of late sepsis, which presented four years after surgery. During the operation one tibial fracture occurred. One distal screw backed out. The fixation was removed from three patients, one for late sepsis, one for septic nonunion, and the patient in whom the tibia fractured

Purpose: Demonstrate the importance of surgical repair of soft tissue damage in an orthopaedic surgery unit. Material and methods: This retrospective study included 455 patients who underwent soft tissue flap surgery between April 1980 and April 2000. There were a total of 556 flaps, hand and finger flaps were excluded from the analysis. Overall results concerning the general treatment for the underlying conditions was not analysed. There were 132 women and 313 men, mean age 42 years. Among these patients 276 (60%) were referred from other hospitals for secondary care. Most of the tissue damage (373 patients among the 455) concerned the lower limb. The soft tissue loss was part of a bone and joint problem in most cases, including: septic nonunion and osteitis (189 patients), trauma and complications after planned orthopaedic surgery (74 patients), grade IIB or IIIC open fractures according to the Gustilo classification (66 patients). There were a total of 485 pediculated or fasciocutaneous muscle flaps and 71 free flaps. Results: Flap survival rate was 90.32%. The result was total necrosis of the flap in 9.68%. The rate of failure was 30% for free flaps and 5% for pediculated flaps. Discussion: This study demonstrated the usefulness of surgical care of soft tissue damage in an orthopaedic surgery unit, particularly for trauma and infection patients. The large number of pediculated flaps is an expression of the reliability of this technique easily applied in a polyvalent orthopaedics traumatology unit. The high rate of failure for free flaps is related to the inherent risk of secondary repair and the inflammatory or infected nature of the soft tissues and also the difficulty encountered in controlling this type of surgery under such conditions. The data reported here allow individual analysis by type of pathology. Conclusion: Overall management of bone and joint disease patients requires proper skill in soft tissue repair

AIMS. Pure tibial plafond traumatic pathology (excluding trimalleolar fractures) is rare but troublesome, considering the surgical challenges and the long term disability perspective. Treatment involves a wide variety of implants and techniques, and the procedures choice and timing is highly dictated by the soft tissue damage. We designed this study to assess the status of our patients operated with internal, external or combined procedures. METHODS. In a retrospective study, between July 2008 and July 2010 we reviewed 24 patients with available follow-up data. We reviewed the pre- and post-operative imaging available and the immediate follow-up data. A form is currently mailed to the patients to self-evaluate the general physical, mental and employment status, and also the affected limb, using general approved questionnaires. Data from this form is still in process. RESULTS. In this clinic we recorded 24 patients with tibial plafond fractures (17 male, 7 female, 2.43 sex ratio), with ages between 18 and 82 years (average 46.5, median 39 years). According to AO/OTA classification, we noted 8 type A (2 A1, 3 A2, 3 A3) extra-articular tibial fractures, 9 type B (4 B1, 4 B2, 1 B3) intra-articular pilon fractures and 7 type C (3 C1, 1 C2, 3 C3) both epi- and metaphyseal tibial fractures, usually with peroneus fractures at various levels. 10 of these fractures were open, from them 3 type IIIA and 2 IIIB Gustilo-Anderson, and 3 of the patients were politrauma (1 L1 lumbar fracture and distal radius fracture, 1 cranio-cerebral trauma and type I open distal radius fracture and 1 cranio-cerebral trauma). We performed a large array of surgical procedures, usually in emergency, based mainly on the local soft tissue status and both the age and recovery needs of the patient. In old debilitated patients we preferred to use minimal internal osteosynthesis, usually applying a supplementary external fixator or cast. In young active patients we used MIPO techniques in tibial fractures, both with regular or locking-screw plates, repairing also the peroneus in order to preserve the limb length in diaphyseal fractures, and to reconstruct the ankle in lateral malleolus fractures. In cases with severe soft tissue impairment we delayed the definitive osteosynthesis using an external fixator. The short term outcome was good, noting only one septic nonunion, which healed with the appropriate treatment, one calcaneus pin track infection and one deterioration of the external fixator in an alcoholic patient. Data for the mid-term outcome is still under evaluation. CONCLUSIONS. Choosing the appropriate procedure is vital for the outcome. Timing is important, especially in high energy trauma, when the proper surgery performed in emergency allowed us to overcome most of the possible complications. Short term results are encouraging, and the mid-term results will let us know if our attitude was correct

Purpose: The bifoliated vascularised fibula graft is an attractive alternative for reconstruction of large bone segments. The purpose of this work was to evaluate mid-term results and the usefulness of two surgical techniques: skin island flap monitoring and the arterio-venous loop. Material and methods: This retrospective analysis included fourteen patients (eleven men and three women) treated between 1992 and 2002. Mean age was 30 years (10–54). Indications were complications of open fractures in nine patients, major bone loss in two, septic nonunion in four, and aseptic nonunion in three. Reconstruction was performed after bone tumour resection in five patients involving immediate reconstruction after failure of an infected massive allograft in four of them. Localisations were: tibia (n=6), femur (n=5), humerus (n=2), and pelvis (n=1). Average bone loss was 10 cm (7–15 cm). Minimal pinning, cerclage or screwing was used to stabilise the flap completed by internal fixation in four patients and external fixation in ten. A monitoring skin island was used for twelve patients (the island was technically impossible in two patients). Vascular anastomoses were performed in seven patients using an arteriovenous loop, performed as a preliminary measure in six. Results: Mean follow-up was 35 months. One patient died early from tumour progression. Among the seven patients who had an arteriovenous loop, one required revision for a vascular complication. For the seven “classical” bypasses, there were three intraoperative or early complications requiring revision of the anastomoses. Nonunion developed despite early revision in the four patients whose monitoring skin island suffered. Consolidation was achieved without revision in all patients who skin island did not suffer; time to bone healing was eleven months for seven of them. Conclusion: Bone healing was related to the quality of graft vacularisation. Clinical observation of the monitoring island was the best way to identify vascular complications early and initiate treatment. Use of a preliminary arteriovenous loop decreased the risk of vascular insufficiency inherent with long bypasses and shortened operative time

Purpose: Nonunion of the tibia is a therapeutic challenge requiring a good understanding of bone healing, bone substance loss and skin trophicity disorders. The fibula pro tibia Huntington procedure consists in transposing the homolateral fibula onto the injured tibia. This allows bridging the bone defect, realignement and stabilisation of the nonunion segment. Material and methods: This retrospective series included eleven patients (ten men and one woman), mean age 32 years (16–62). The cause of the injury was a traffic accident in six cases, defenestration in one, adamatinoma in one and osteomyelitis in one. The skin was broken in nine patients with septic nonunion in seven. Mean follow-up was 13 years (1–21). Results: Mean delay to healing was 10.5 months (8.5 for post-traumatic nonunions) and was achieved in eight cases. A higher tibial nonunion persisted after resection of an adamantinoma measuring 22 cm and two patients had to be amputated in a context of acute suppuration. Walking without crutches was possible for eight patients whose tibia had healed and the mean pain score was 2 / 10. Discussion: Several solutions can be proposed for patients with a tibial nonunion. The inter-tibiofibular graft requires a large bone graft in patients who have already had several operations. Th Papineau method only provides cancellous bone which is mechanically weak. The Ilizarov method can allow bone transfer and dynamisation of the nonunion with compression distraction. Microanastomosis transfers using a free fibula require a trained team with the risk of potential infection of the anastomoses in these infected patients. The Huntington method has the advantage of providing osteosynthesis without the inconvenients of inert material. The fibular acts like a biological plate with good vascularisation and stability to realign and lengthen the tibial segment. Conclusion: This surgical technique is a supplementary therapeutic means for treating (septic) nonunion of the tibia. It is easy to perform and may be the last salvage method. The advantages are: a solid compact graft fixed in the mechanical axis of the tibia, possibility of bridging bone loss of more than 28 cm, short operative time without risk of complications related to graft harvesting, shorter hospital stay

Aims

The aim of this study was to evaluate the radiological outcome of patients with large bone defects in the femur and tibia who were treated according to the guidelines of the diamond concept in our department (Centre for Orthopedics, Trauma Surgery, and Paraplegiology).

Aims

Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure.