Surgical treatment of distal tibia fractures is usually associated with extensive soft tissue compromise and high complication rates (infection, delayed or non-union, ankle stiffness and osteoarthritis). Wound infection is one of the most common complication (deep infection rates up to 15%) and can develop into an infected non-union. In 1973, Papineau described a staged technique for treating infected non-union of long bones, consisting of (1) surgical debridement of necrotic tissue, temporary splinting, specific antibiotic treatment, postoperative wet-to-dry wound dressing changes; (2) packing of the bone defect with cortico-cancellous autograft; (3) closure of the soft-tissue wound by a flap or secondary intent. The authors aim to report a clinical case of a successful treatment of a distal tibia infected non-union with the Papineau technique and negative-pressure wound therapy. Woman, 56 years-old, referred to Orthopaedic consultation on October 2013 for wound dehiscence and infection with a methicillin-resistant Staphylococcus aureus, one month after open reduction and internal fixation of an open distal tibia fracture. On November 2013 she underwent surgical debridement, removal of osteosynthesis material, osteotaxis with external fixator, negative-pressure wound therapy and antibiotic treatment with intravenous vancomycin 1g 12/12h (1st stage of Papineau procedure). On December, she underwent autologous iliac crest cancellous bone grafting and wound care, daily irrigated with saline solution (2nd stage). On February 2014, she underwent a partial thickness skin graft for wound closure (3rd stage). On April, the external fixator was removed and there was still no evidence of union. She had pain, disuse osteoporosis, ankle and midfoot stiffness, and was sent to physical therapy. On April 2015, she can full weight bear with mild pain, the soft tissue envelope is in good condition, the fracture has united and she has an Ankle AOFAS Score of 83. The Papineau technique has been used for the management of infected non-unions with bony defects, with high success rates. Complete necrotic tissue debridement and targeted antibiotics are fundamental for obtaining a viable and healthy tissue, able to receive the bone graft. Negative-pressure wound therapy is important in reducing the bacterial load, improving the microcirculation and enhancing the granulation tissue. In the present case, the combination of the two techniques probably acted together in achieving successful eradication of the infection, reconstruction of the bone defect and soft tissue closure

Aim. Negative-pressure wound therapy (NPWT) is often propagated as treatment option for fracture-related infection (FRI). After surgical debridement and repeated NPWT dressing changes, the wounds are often closed by free flaps. Sometimes even healing by secondary intention seems an alternative. Recently, concerns have been raised on the long-term use of NPWT as it could be related to bacterial overgrowth and possible re-infection. The purpose of this study was to conduct a retrospective evaluation of the influence of long-term NPWT on tissue culture results and outcome in FRI patients. Method. Between January 1. st. , 2015 and December 31st, 2018, a total of 852 patients were treated with NPWT for different indications on the Department of Trauma Surgery. Inclusion criteria for this study were patients with a closed fracture, stabilized with osteosynthetic fixation and complicated with a confirmed FRI according to the FRI consensus definition. Patients were included when they received at least three NPWT dressing changes in the operating room. Exclusion criteria were patients younger than 18 years, or the absence of cultures results from dressing changes. Results. During the study period 23 patients met the inclusion criteria. According to the tripartite classification of Willenegger and Roth, one patient had an early, 14 a delayed and 8 patients a late onset FRI. Overall, 139 NPWT dressing applications were performed, with an average amount of six per patient. In 14 patients (61%) and 57 dressing changes (41%), at least 2 tissue cultures showed the same pathogen or at least one, in case of highly virulent organisms (e.g. S. aureus) during a single dressing exchange. Coagulase-negative staphylococci were present in 33% of the cases, followed by Enterococcus spp. (21%), S. aureus (16%), non-fermentative gram negative bacilli (14%) and Enterobacteriaceae (7%). Furthermore, 17 exchanges showed polymicrobial growth. Five patients had repeatedly significant growth of the same pathogen despite adequate antimicrobial therapy, within this group one patient was immunocompromised. Conclusions. In a large amount of patients (61%), a significant number of positive culture results could be acquired, even in the presence of adequate local and systemic antimicrobial therapy. The clinical relevance of these results remains unclear. This said, it seems important to limit the duration of NPWT as prolonged treatment could increase bacterial overgrowth and possible (re-)infection. Therefore, a rapid definitive soft tissue coverage should be encouraged. Future larger prospective clinical trials are required

Introduction. The incidence of periprosthetic fractures is increasing as the population ages. Wound complications and surgical site infections following surgery to treat periprosthetic fractures are a major source of patient morbidity and health care burden. This study evaluates the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing wound complications and surgical site infections (SSIs) after periprosthetic fracture surgery about the hip and knee. Methods. An IRB-approved retrospective quality improvement analysis of sixty-five consecutive periprosthetic fracture surgeries performed by four surgeons at a single institution in a fifteen-year period was performed. ciNPT was selectively used on patients in the last 20 months of the study period. Rates of wound complications, surgical site infections, and reoperation were compared with those of a sterile antimicrobial dressing (AMD). Results. AMD was used on 44 patients, while ciNPT was used in 21 patients. Compared with those treated with AMD, patients treated with ciPNT developed fewer wound complications 5% (1/21) vs 25% (11/44) (p = 0.045), deep infections 0% (0/21) vs 20% (9/44) (p = 0.014), and underwent fewer reoperations 5% (1/21) vs 20% (9/44) (p = 0.045). All patients had at least thirty days of follow up. Conclusion. Our findings suggest that ciNPT decreases the incidence of wound complications, deep infections, and reoperations in patients requiring surgical management of periprosthetic fractures about the hip and knee

Aim. Optimal strategies for surgical and antimicrobial management of Candida periprosthetic joint infections (PJI) are unclear. We present a retrospective case series of patients diagnosed with PJI caused by Candida spp. Method. Patients treated at our institution with Candida PJI from 01/2017 to 04/2018 were retrospectively included with isolation of Candida spp. in synovial fluid, intraoperative tissue or sonication fluid culture. PJI was defined by the proposed European Bone and Joint Infection Society (EBJIS) criteria. Treatment failure was defined as relapse or persistence of infection. Results. We included 9 patients (4 men and 5 women, mean age 75 years) involving 4 knee and 5 hip joint prosthesis. Risk factors for Candida PJI were prior PJI (n=4), diabetes mellitus (n=3), chronic kidney disease (n=3), obesity (n=3), negative-pressure wound therapy (n=3), rheumatoid arthritis (n=1) and chronic decubitus (n=1). Two patients had no risk factors for Candida PJI identified. Infection was acquired postoperatively (n=7), hematogenously (n=1) or contiguously through communicating vesico-articular sinus (n=1). The causative pathogen was C. albicans in 5, C. parapsilosis in 3, C. tropicalis in 1 patient, isolated from periprosthetic tissue samples (n=7), sonication fluid (n=3) and blood cultures (n=2); bacterial co-pathogens were isolated in 8 patients. Histopathological analysis revealed low-grade inflammation in all 6 patients, in whom it was performed. All patients were treated with oral fluconazole for 3 months, two initially received intravenous caspofungin and three received suppression with oral fluconazole for additional 9 months (total treatment 12 months). Liposomal amphotericin B (300–700 mg per 40 g bone cement) was admixed to spacer cement in 3 patients. Debridement and prosthesis retention was performed in one patient with tumor prosthesis after bone resection due to osteochondrosarcoma. In the remaining 8 patients the prosthesis was removed, with one-stage reimplantation in 1 patient and two-stage reimplantation in 3 patients (after 6 weeks, 3 months and 7 months); two patients are currently awaiting reimplantation, one died due to reason not related to PJI and another underwent knee arthrodesis. Among 5 patients with prosthesis in place, relapse occurred in one patient with prosthesis retention. Another patient experienced new PJI of the exchanged prosthesis caused by Staphylococcus aureus. Conclusions. All Candida PJI presented as chronic infection with low-grade inflammation. Treatment with prostheses retention failed, whereas in 4 patients who underwent two-stage exchange and long-term antifungal suppression, no relapse or persistence of infection was observed. All patients received oral fluconazole for ≥3 months