The purpose of the study was to retrospectively assess the patients treated to date with the vac ulta system using a technique of antibiotic instillation. The vac ulta system is licensed for use with anti-septic instillation fluid but we have now treated a number of patients with antibiotic instillation under the guidance of the microbiology department. All patients being treated with the vac ulta system were included in the study. There were no exclusions. Pathology treated, infecting organism, antibiotic used and length of treatment were all recorded. Any antibiotic related complications were noted. Treatment was judged successful with resolution of presenting symptoms, normalization of inflammatory markers and three negative foam cultures. There were 21 patients included in the study. There were 13 male and 8 female patients. Length of treatment ranged from 1 week to 10 weeks with a mean of 4.2 weeks. Follow up ranged from 1 month to 42 months with a mean follow up of 17.9 months. The most common pathogen was Staph. Aureus(11 cases). Enterobacter, ESBL, Strep. Milleri, MRSA and Citrobacter were also treated. Antibiotics instilled included flucloxacillin, meropenem, gentamicin, vancomycin, meropenem and teicoplanin. There were no antibiotic reactions/allergies. Pathologies treated included osteomyelitis, two stage amputations for infection, infected non-union and infected metalwork. Infection recurred in 2 of 21 patients (10%), with one recurring at 18 months and one at 2 years. The 90% treatment success rate is highly encouraging in this notoriously difficult group of patients to treat. In this series vac instill was an effective treatment of infection and allows antibiotic treatment to be targeted to the infected tissues. There were no adverse reactions seen. Larger series with longer follow up are no needed but we believe this technique is safe, successful and easily administered can be cautiously adopted on a wider basis

Aim. The purpose of this study is to analyze the demographic and microbiological variables of acute ankle infections posterior to ankle osteosynthesis and to determine the different characteristics of patients withE. cloacae infection. Method. A multicenter retrospective observational study (4 national hospitals) of acute post osteosynthesis infections of ankle fracture operated between 2015 and 2018 was implemented. The demographic and microbiological variables relating to the surgical intervention and the antibiotic treatment performed were collected. A descriptive assessment of all the variables and a univariate comparison between patients with E. cloacae infection and patients with alternative microorganism infections were performed. The SPSS v25 program for Windows was the choice for statistical analysis. Results. 71 Patients with an average age of 57 years were included, the majority being males (55%). 31% of patients were diabetic, 27% had vascular pathology, and 18.3% had a BMI greater than 35. Trimalleolar fracture was the most common in our study being 52%. 26.8% were open fractures. The microorganisms isolated were: 25% S. aureus, 22.5% E. cloacae and 22.5% polymicrobial. Accounting for polymicrobial infections, the presence of E. cloacae rises to 32%. In the univariate analysis, only significant differences were found in age (patients with E. cloacae infection were older) and the use of VAC therapy. Conclusions. In our series, higher percentages of E. cloacae infection were observed than those described in the literature. There are statistically significant differences in the variables of age and need for VAC therapy. The high incidence of E. cloacae infections suggests the vital importance of adapting antibiotic prophylaxis, ensuring the coverage of this microorganism

Aim. Pelvic osteomyelitis following pressure ulceration results in substantial patient morbidity. Previous studies have reported a heterogenous approach to diagnosis and medical management by physicians, suggesting equipoise on key clinical questions. This study hypothesised that the same equipoise exists amongst Orthopaedic surgeons. Method. An 18-question multiple-choice questionnaire was designed through an iterative feedback process until the final version was agreed by all authors. Likert-type scale responses were used with graded responses (e.g., never/fewer than half of patients/around half of patients/more than half of patients/every patient). The online survey was sent to members of the Musculoskeletal Infection Society (MSIS), the European Bone and Joint Infection Society (EBJIS), and the ESCMID Study Group for Implant-Associated Infections (ESGIAI). No incentive for participation was provided. Results. Amongst respondents, 22/41 were based in Europe and 10/41 from the USA. The majority (29/41) had been in clinical practice between 5—24 years. There was a high priority placed on bone biopsy histology, culture-positive bone sampling, and palpable bone without periosteal covering for diagnosis. Multidisciplinary team approach with plastic surgery involvement at the index procedure was advocated. The strongest indications for surgical intervention were source control for sepsis, presence of an abscess/collection, and prevention of local osteomyelitis progression. Physiological/psychological optimisation and control of acute infection were the primary determinants of surgical timing. There was low utilisation of adjunctive surgical therapies. Local/regional primary tissue transfer or secondary healing with/without VAC were the preferred techniques for wound closure. Recurrent osteomyelitis was the most common reason for prolonged antimicrobial therapy. The majority received bedside advice from an infectious disease-specialist but a quarter of respondents preferred telephone advice. Conclusions. Amongst an international cohort of Orthopaedic Surgeons there was a heterogenous diagnostic and therapeutic approach to pressure-related pelvic osteomyelitis

Aim. Negative pressure wound treatment (NPWT) has been widely adopted in the management of septic wound complications or prophylactically after large surgeries. Recent publications have indicated the necessity of further investigations to support the use of NPWT with more evidences. Therefore, the purpose of this pilot-study was to investigate the efficacy of VAC-assisted dressing systems in the treatment of septic trauma cases. Method. We analysed data of 16 retrospective cases following traumas and septic soft tissue surgeries around the hip and knee. The collected data consisted of bacterial cultures, inflammatory markers (WBC, CRP/HCRP) and body temperature, taken periodically during treatment. Also recorded were the time periods the vacuum pump was used during treatment. To increase the number of measurements and to facilitate subsequent data analysis, the measurements were interpolated to regularly sampled curves with a sampling rate of one day. We used cross-plots and linear regression analysis to investigate trends in the data: 1) while the vacuum pump was switched on and 2) while it was switched off. Results. The analysis shows that the average WBC and CRP/HCRP values decline in the first days after initiation of the VAC treatment. WBC values decline in the first four days of VAC treatment (linear regression, R. 2. =0.960). CRP/HCRP values decline in the first thirteen days (linear regression, R. 2. =0.952). No meaningful trends were observed in body temperature measurements. Importantly, there is a trend for an increase of WBC and CRP/HCRP, following the 4. th. and 14. th. days, respectively. These findings suggest that the prolonged use of VAC treatment may result in secondary relapses. Conclusions. Our results indicate a marked decrease of inflammatory markers during the first two weeks, confirming the efficacy of NPWT in the management of septic wounds after traumas. Importantly, our analyses also show a periodic relapse with the prolonged use of NPWT. However, further studies are needed with a larger, standardized population to confirm these findings

Chronic posttraumatic osteomyelitis (CPTO) is a complex condition that results in considerable morbidity and may be limb threatening. Tibia is the most common site of CPTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Adequate soft-tissue coverage is one of the cornerstones in chronic osteomyelitis management. Vacuum-assisted closure (VAC) is frequently used for the treatment of posttraumatic osteomyelitis of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. Free muscle flaps are recommended in distal third tibial defects. We present our experience with two case reports. The authors present two cases of type IIIA osteomyelitis according to Cierny-Mader classification, following previous distal third tibial open fractures. Both patients presented with limb deformity, insidious local pain and chronic purulent discharge (without significant local inflammatory signs) after 11 and 24 years of trauma. They were treated with radical debridement of all nonviable and infected tissue, VAC instillation therapy for 3 weeks and transverse rectus abdominis muscle (TRAM) flap defect coverage. Intra-operative cultures were positive for multiple pathogens. Specific antibiotic therapy was performed for each case for 8 weeks. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values. No complications were documented. 1 year post-surgery, both patients remain asymptomatic, with no signs of infection, with full flap integrity and gait without assistance. Despite the challenging management of chronic posttraumatic osteomyelitis of the tibia, infection control and a satisfactory functional outcome can be achieved. The cornerstones of management include infection control with surgical debridement, microbial-specific antibiotic administration and soft tissue coverage. VAC instillation therapy has an important role promoting granulation tissue formation and infection eradication. The aggressive approach, even with delay on diagnosis, is the key factor for a worthy outcome. Despite the good results, recrudescence of osteomyelitis is known to occur even years after the original offense is treated

Wound complications are much more common following knee arthroplasty as compared to hip arthroplasty, due in part to the precarious blood supply to the knee, as well as the subcutaneous position of the joint. Many, if not most, infections are related to wound problems, and thus avoiding wound problems is a critical issue in knee replacement surgery. Many wound problems are avoidable and can be minimised by care to detail by the surgeon. The important steps are to first identify patients at risk and optimally addressing these risk factors. Patient risk factors include: chronic corticosteroid use, diabetes, rheumatoid arthritis, malnutrition, obesity, and smoking. Soft tissue handling is a second major issue. Minimal incision surgery should be used with great caution for knee replacements since the skin is much less forgiving than in hip replacements. A midline skin incision should be utilised when possible. When multiple incisions are present it is usually advisable to use the lateral most incision through which it is feasible to perform a knee replacement. In rare cases, a soft tissue expander may be used preoperatively for thin, adherent skin. Perioperative steps that can be taken include delaying CPM in high risk wounds, and using a wound vac system in obese or other high risk wounds to minimise persistent drainage. Furthermore, anticoagulation should be used judiciously to avoid prolonged drainage. The final step in salvaging the problem wound is early recognition and aggressive management of wound healing problems. Prolonged, serous drainage is the most common clinical scenario. Drainage that is increasing beyond 5–7 days frequently requires evacuation, irrigation, debridement, and liner exchange. Early aspiration can decompress a hematoma and also rule out infection

Material and methods:. Fifteen patients sustaining high energy Gustilo 3B injuries of the tibia were treated from 2003 to 2009 with initial debridement followed by application of an external fixation device allowing immediate acute shortening of the bone gap. The bone defects ranged from 3 cm to 5 cm. Wound management was achieved with a vacuum assisted closure device (VAC) until granulation tissue covering the exposed bone made coverage with split skin grafting possible. A delayed progressive lengthening procedure was used to equalize the leg length discrepancy after wound cover was achieved. Results:. The mean age of the 15 patients was 30 years and treatment times varied from 4 to 12 months. All fractures united with acceptable alignment and equalization of the leg length discrepancy. One patient required repeat procedures for a pin site infection by changing a wire. There was no deep sepsis. Conclusion:. This method is a satisfactory and safe alternative for the acute management of the compound wound, when plastic surgery skills are either unavailable or flap cover is contraindicated in the presence of sepsis or as a salvage procedure following flap failure. Wire placement needs to be carefully planned in order to accommodate initial VAC placement, followed by final definitive fixation after wound cover has been achieved

Wound complications are much more common following knee arthroplasty as compared to hip arthroplasty, due in part to the precarious blood supply to the knee, as well as the subcutaneous position of the joint. Many, if not most, infections are related to wound problems, and thus avoiding wound problems is a critical issue in knee replacement surgery. Many wound problems are avoidable and can be minimised by care to detail by the surgeon. The important steps are to first identify patients at risk and optimally addressing these risk factors. Patient risk factors include: chronic corticosteroid use, diabetes, rheumatoid arthritis, malnutrition, obesity, and smoking. Soft tissue handling is a second major issue. Minimal incision surgery should be used with great caution for knee replacements since the skin is much less forgiving than in hip replacements. A midline skin incision should be utilised when possible. When multiple incisions are present it is usually advisable to use the lateral most incision through which it is feasible to perform a knee replacement. In rare cases, a soft tissue expander may be used pre-operatively for thin, adherent skin. Peri-operative steps that can be taken include delaying CPM in high risk wounds, and using a wound vac system in obese or other high risk wounds to minimise persistent drainage. Furthermore, anticoagulation should be used judiciously to avoid prolonged drainage. The final step in salvaging the problem wound is early recognition and aggressive management of wound healing problems. Prolonged, serous drainage is the most common clinical scenario. Drainage that is increasing beyond 5–7 days frequently requires evacuation, irrigation, debridement, and liner exchange. Early aspiration can decompress a hematoma and also rule out infection

Introduction. Recurrent dislocation after hip arthroplasty is a difficult problem. The purpose of the present study was to evaluate the results with the use of a constrained cup for treatment for instability after hip arthroplasty. Materials/Method. A prospective database of 30 patients who underwent revision hip surgery for dislocation of hip arthroplasty was kept with the surgeries taking place between Nov 2005 to Feb 2010. Results. The mean age of the cohort was 76.5 years (53–93 years) with 17 female and 13 male patients. The gap between primary hip surgery and constrained cup ranged from 1 week to 21 years. The follow-up ranged from 8 months to 62 months with an average of 31 months. The primary surgery was a total hip arthroplasty in 27 patients and cemented hemiarthroplasty in 3 patients. Femoral component revision was done in 6 patients. At latest clinical follow-up 16 patients were mobilising unaided and 6 needed some support. Post-operative complications included capture cup pullout from the sidewall of the pelvis in the first week post op. Infection complicated 2 patients with one patient ending up having a girdlestone type excision and the other treated with antibiotic suppression. One patient had post op problems of wound dehiscence treated with VAC therapy. Conclusion. This is a useful technique for a difficult management problem

To evaluate the value of the use of massive prostheses in periprosthetic infections both in one stage and two stages procedures. Between 2008 and 2014, 236 revisions for PJI had been performed in our hospital by the same surgeon. For the most complex cases, we decided to introduce megaprostheses in our practice in 2011. We report a prospective series of 33 infected patients treated between 2011 and the end of 2014, 14 male and 19 female with on average 67.9 years old (38–85) Infection involved TKA in 22 cases (17 TKA revisions, 4 primary TKA), THA in 9 cases (6 revisions, 3 primary THA), a femoral pseudo-arthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used a total femoral component for two patients: the first one for a hip PJI with extended diaphyseal bone loss and multiples sinus tracks, and the second one for a massive infected knee prosthesis used in a knee reconstruction for liposarcoma. We used one stage procedures in 20 cases (8 hips, 12 knees, 1 shoulder) and two stages in 13 cases (12 knees and 1 hip). Additional technics included 3 massive extensor system allografts, two local flaps. Perioperative hyperbaric treatment was used for 2 patients. The average follow up is 19.8 months (6–48 months). The most frequent complications were wound swelling and delayed healing in 8 cases;). In 3 cases of one stage surgery a complementary debridement was necessary in the three weeks after the surgery with always a good local and infectious evolution. VAC therapy was used in four cases with good results. We report one early postoperative dead. In summary, the use of massive prostheses in PJI is a good option for complex cases. It can be a good alternative to knee arthrodesis. These components must be used preferentially for older patients, in cases of extreme bone loss or extensive osteomyelitis to secure the bone debridement and the quality of the reconstruction. In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. We believe the two stages surgery is a secondary option, particularly when soft tissues status is compromised before or after the debridement, and mostly for the knees. The longevity of the implantation must be evaluate by a long term follow up

Necrotising fasciitis (NF) of the extremities is a rapidly progressive, potentially life threatening soft tissue infection. Recent advances in its management, like hidrobisturi-assisted debridement (Versajet®), negative pressure wound therapy (NPWT), or Intravenous Immunoglobulin (IVIG) have not clearly influenced in mortality and morbidity rates, still high. We therefore sought to study the necrotising fasciitis of the extremities diagnosed in the last four year in our hospital. We investigate (1) the morbidity and mortality rates, (2) the microbiologic characteristics of the infection, and (4) the management focusing on the use of new treatment technologies. This is a 4-year retrospective chart review of all NF of the extremities who presented in our hospital, from 2010 through 2013. We collected data on demographics, comorbidities, diagnostic test, LRINEC score and microbiological information. We evaluated the therapeutic management of these patients, focusing in the intensive care necessities, the use of hidrobisturi and NPWT as well the treatment with IVIG. 20 patients satisfied our inclusion criteria. Lower extremity was the most common location of infection (60%). Blood cultures were available in 14 cases, 7 with a negative culture result (50%). The average LRINEC score on the day of presentation was 6 (range: 0–11). All the patients were treated operatively with 2.5 interventions on average (range: 1 to 5 operations). In the operative samples, one or more causative microorganisms were identified in 18/20 (90%) of the NF cases, with two culture negative cases. Overall, type II NF (Group A β-haemolytic streptococci) was found in 11 cases (55%) and Type I (synergistic polymicrobial) in 7 cases (35%). Versajet® was used in the first debridement in 40% (8 out 20) of the cases and in the second-look in 80% of the cases. In 5 cases (25%) a direct wound closure was selected and in 75% cases a VAC closure was the technique of choice. Thirteen patients (65%) were admitted in the intensive care unit, with a medium stay of 12 days. The overall mortality was 30 % with LRINEC score, glucose level and creatinin level being an independent risk factor of death (p < .05). Five amputations were identified in this series (25%). According our data, despite surgical advances, pharmacological new drugs and intensive care improvements, NF remains a disease with high mortality and morbidity. New technologies have been used widely in the last four years in our center without appearing to influence the final outcome of the disease

We present a novel approach to the management of patients with longstanding heel ulcers complicated by open calcaneal fractures. The principles of management of diabetic foot ulcers were combined with applied physiology of fracture healing. Case notes of 6 consecutive patients who presented to our diabetic foot clinic between January 2009 and December 2009 were reviewed. Type of diabetes, duration of heel ulcer, type of fracture and treatment given were recorded. Initial treatment consisted of regular local debridement and application of dressing. Vacuum Assisted Continuous (VAC) pump application was deferred until 6 weeks to preserve fracture hematoma and thereby initiate fracture healing. In all patients, VAC pump was started at 6 weeks and continued till healing of ulcer to adequate depth. Infection was treated aggressively with appropriate antibiotics according to the microbiology results. The average age was 53 (40-60) and the mean duration of follow up was 6 months. All wound healed completely, fractures united and patients returned to previous function. An open calcaneal fracture presents a severe injury likely to be complicated by infection and consequent osteomyelitis leading to amputations. In our group of patients, a novel treatment approach consisting of multidisciplinary model resulted in successful limb preservation and return to function

Background. Although soft tissue sarcoma (STS) is a rare malignancy, myxofibrosarcoma is a common form diagnosed. Myxofibrosarcoma is complicated by a high local recurrence rate (18–54%) and significant morbidity following treatment, hence management can be challenging. Patients and Methods. Patients treated between 2003–2012 were identified via a database within the histopathology department and case notes were retrospectively assessed. All histology samples were reviewed by a senior histopathologist to ensure a correct diagnosis. Results. 29 patients (12 male, 17 female) with an average age of 61 years (range 19–89 years) underwent surgery at a single centre, with 24 patients receiving adjuvant and two receiving neo-adjuvant radiotherapy. 22 patients had lower limb and 7 had upper limb tumours. 3 were treated for secondary recurrence after having primary surgery elsewhere. 21 patients had Trojani Grade 2 or 3 tumours. All underwent limb-sparing surgery initially but six patients (20.7%) suffered local recurrence after an average follow-up of 28 months and all ultimately required above knee amputation. Four patients developed wound infection, with one requiring VAC therapy. One patient required a flap repair of the forearm. 5-year survival rate was 87.5%. Conclusions. Our results compare favourably against results published so far in the literature with a low local recurrence rate and mortality. Limb-sparing surgery aims to reduce morbidity and disability following treatment but more research is required in adjuvant treatments to further reduce the risk of local recurrence of tumour