Aim. Bone infections often manifest with soft tissue complications such as severe scarring, fistulas, or ulcerations. Ideally, their management involves thorough debridement of infected bone and associated soft tissues, along with achieving stable bone structure, substantial tissue coverage, and long-term antibiotic therapy. The formation of a multidisciplinary team comprising orthopedic surgeons, plastic surgeons, and infectious disease specialists is essential in addressing the most complex cases. Method. We conducted a retrospective study during six years (2018-2023) at our university center. Focusing on the most challenging cases, we included patients with bone infections in the leg and/or foot requiring free flap reconstruction. Each patient underwent simultaneous bone debridement and reconstruction by the orthopedic team, alongside soft tissue debridement and free flap reconstruction by the plastic surgery team. Targeted antibiotic therapy for either 6 weeks (acute) or 12 weeks (chronic osteitis) was initiated based on intraoperative cultures. Additional procedures such as allografts, arthrodesis, or autografts were performed if necessary. We analyzed the rates of bone union, infection resolution, and limb preservation. Results. Forty-five patients were enrolled. Twenty-four patients (53.3%) had urgent indications (e.g., open infected fractures, osteitis, acute osteoarthritis, or wound dehiscence), while 21 (46.7%) underwent elective surgery (e.g., septic pseudarthrosis or chronic osteitis). Two patients underwent amputation due to flap failure (4.4%), and one patient was lost to follow-up. Follow-up of the remaining 42 patients averaged 28 months (range: 6–60 months). During this period, 35 patients (83.4%) experienced no recurrence of infection. Similarly, 35 patients (83.4%) achieved bone union. Overall, the rate of lower limb preservation was 93.3%. Conclusions. Managing bone infection coupled with soft tissue defects brings significant challenges. Although the majority of patients treated here belong to a complex framework based on the BACH classification, the outcomes achieved here appear to align with those of the simpler cases, thanks to optimal care with a dedicated septic ortho-plastic team. Our study demonstrates a notable success rate in treating infection, achieving bone consolidation, and preserving lower limb function

Introduction. Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups. Materials & Methods. A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests. Results. 79 patients with open fractures of the tibia were included. 70.8% of patients were male, with mean age 50.4 years (SD 19.2) and BMI 26.4 Kg/m2 (SD 6.0). Injuries were mostly sustained by low-energy falls (n = 28, 35.4%) and from road traffic accidents (n = 26, 32.9%). 27 (34.2%) were OTS simple open fractures. Simple open fractures were most commonly Gustillo-Anderson grade 1 (38.5%), or 2 (30.8%), whilst complex open fractures were mostly grade 3B (66.7%) (p < 0.001). Fracture-related infection rates in OTS simple and complex open fractures were 25.9% and 25.5% respectively (p = 0.967), and nonunion rates were 32% and 37.8% (p = 0.637). Primary amputation was less common in simple (0%) than in complex open fractures (20%, p = 0.012), there were no differences in delayed amputation rates (7.4% and 6% respectively, p = 0.811). Simple open fractures were less likely to have plastic surgeons present at initial debridement compared to complex open fractures (18.5% and 44%, p = 0.025), and less likely to have bone ends delivered through the skin at initial debridement (25.9% and 61.2%, p = 0.003). There were no differences in patient age, delays to antibiotic administration, or reoperation rates between OTS simple and OTS complex fractures (p > 0.05). Conclusions. Despite involving less significant soft tissue injury, OTS simple open tibia fractures had comparable deep infection and nonunion rates to complex fractures and received early plastic surgical input and adequate debridement less frequently. The severity of open fractures with less significant soft tissue injury may be underrecognized and therefore undertreated, although further prospective study is needed

Introduction. Open fractures are fortunately rare but pose an even greater challenge due to poor soft tissues, in addition to poor bone quality. Co-morbidities and pre-existing medical conditions, in particular, peripheral vascular diseases make them often unsuitable for free flaps. We present our experience in treating severe open fractures of tibia with Acute Intentional Deformation (AID) to close the soft tissues followed by gradual correction of deformity to achieve anatomical alignment of the tibia and fracture healing with Taylor Spatial Frame. Materials and Methods. We treated 4 geriatric (3 female and 1 male) patients with Gustillo-Anderson III B fractures of the tibia between 2017–18. All were unfit to undergo orthoplastic procedures (free flap or local flaps). The age range is 69 yrs to 92 years. Co-morbidities included severe rheumatoid arthritis, multiple sclerosis and heart failure. The procedure involved wound debridement, application of two ring Taylor Spatial Frame, acute deformation of the limb on the table to achieve soft-tissue closure/approximation. Regular neurovascular assessments were performed in the immediate post-operative period to monitor for compartment syndrome and nerve compression symptoms. After 7–10 days of latent period, the frame was gradually manipulated, according to a method we had previously published, to achieve anatomical alignment. The frame was removed in clinic after fracture healing. Results. Time in frame ranged from 1.5 months to 7 months. In one patient (92 yr old with an open fracture of the ankle) hindfoot nail was inserted after soft-tissue closure was achieved at 1.5 months, and frame removed. We achieved complete healing of soft tissue wounds without any input from plastic surgeons in all patients. All fractures healed in anatomical alignment. 3 patients had one episode of superficial pin infection each requiring 5 days of oral antibiotics. None of the patients developed a deep infection. Conclusions. Acute intentional deformation (AID) with Taylor Spatial Frame achieves good closure of soft tissues in physiologically compromised geriatric patients who were deemed unfit for plastic surgery. We also achieved fracture healing in all four cases without any major complications

To propose a national specification for hospitals which offer treatment of complex bone and joint infections to adults. Patients with bone and joint infections are treated in a wide variety of hospitals in the UK. A few have developed services with infection physicians, microbiology laboratory support and dedicated orthopaedic and plastic surgeons working together to deliver a multidisciplinary care pathway. However, many patients are treated in non-specialist units leading to multiple, often unsuccessful procedures with long hospital stays, high costs and additional pain and disability. Inappropriate antibiotic therapy without adequate surgery risks antibiotic resistance. A draft specification was written defining the types of patients who should be referred to a specialist unit for treatment. A description of the components which must be available to treat these cases (staffing, expertise, diagnostic support, outcome assessment and governance structure) was proposed. This draft was circulated to infection units in the UK for consideration and agreed with the Health Department in England. Complex bone and joint infections would be best served nationally by 3–6 networks, each with a single specialist centre. This is similar to national arrangements for bone sarcoma treatment. Patients to be referred will include those with:. Chronic osteomyelitis (long bone, pelvis, spine). Chronic destructive septic arthritis. Complex prosthetic joint infections (multiple co-morbidities, difficult/multi-resistant organisms, multiply operated or failed revision surgery). Infected fractures and non-unions. Specialist units should have:. Orthopaedic surgeons who specialise in infection (joint revision, Ilizarov techniques, etc). Infection physicians who can treat medically unwell patients with complex co-mordidities and multi-resistant infections. Plastic surgeons with experience in difficult microsurgical reconstruction techniques. Scheduled (at least weekly) meetings of all of the above, with a radiologist to discuss new referrals and complex cases. A home IV therapy service. Dedicated in-patient beds staffed by infection trained staff. Multi-disciplinary (one-stop) out-patient clinics. Quality measures assessed, including PROMS, clinical success rates, and functional outcome. Education and research programmes. This service specification is a tool for developing regional units. It facilitates the creation of designated centres in a national network (hub and spoke model). This service specification has been agreed and published by NHS England

Aim. Calcaneal osteomyelitis is an uncommon and challenging condition. In this systemic review we aim to analyse the concomitant use of bone debridement and soft tissue management for patients diagnosed with calcaneal osteomyelitis. Method. A complete computerised and comprehensive literature search of Pubmed and Cochrane database was undertaken from January 2000 to October 2018. During the review, studies were screened for information about the surgical and antimicrobial treatment, the complications, the reinfection rate and the functional outcome of patients with calcaneal osteomyelitis. Results. Of the 20 studies included, seven (35%) described bone treatment only, six (30%) soft tissue treatment only, five (25%) soft tissue and bone treatment, and two (10%) focused on prognostic factors and differences in outcomes between diabetic and non-diabetic patients. In the studies with bone treatment only, infection recurrence ranged from 0 to 35% and the amputation rate from 0 to 29%. If soft tissue coverage was also needed, both the reinfection rate and amputation rate ranged from 0 to 24%. Studies presenting the functional status showed preservation or even improvement of the preoperative ambulatory status. Conclusions. Calcaneal osteomyelitis is difficult to treat. A multidisciplinary approach involving orthopaedic surgeons, plastic surgeons and infectious disease physicians is necessary for treatment success. Based on the localisation and size of the bone and soft tissue defect, decision for surgical treatment should be made

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 B.A.C.H. system is a new classification for long bone osteomyelitis. It uses the four key inter-disciplinary components of osteomyelitis, namely, bone involvement, anti-microbial options, soft tissue status and host status. This study aims to assess the inter-user reliability of using the B.A.C.H. classification system. Method. We identified 20 patients who had a diagnosis of long bone osteomyelitis using a previously validated composite protocol. For each patient, osteomyelitis history, past-medical history, clinical imaging (including radiology report), photographs of the affected limb and microbiology were presented to clinical observers on an online form. Thirty observers, varying in clinical experience (training grades and consultants, with a variety of exposure to osteomyelitis) and specialty (orthopaedic surgery, infectious diseases and plastic surgery) were asked to rate the twenty cases of osteomyelitis. Before rating, an explanation of how to use the classification system was given to the observers, in a structured ‘user key’. The responses were assessed by accuracy against a reference value and Fleiss' kappa value (Fκ). Results. The 30 users individually classified all 20 cases. The observers comprised 14 orthopaedic surgeons, 13 physicians (either microbiology, infectious diseases or anesthetists) and 3 plastic surgeons. The users had a variety of exposure to osteomyelitis ranging from less than one case per month to greater than one case per week. The accuracy across all variables was 86.2% (95% CI 83.9% – 88.6%, SD 6.2%), with the ‘C’ variable scoring the highest at 92.5% (95% CI 88.5% – 95.6%, SD 8.2%) and the ‘B’ variable scoring the lowest at 77.0% (95% CI 71.2% – 82.8%, SD 15.5%). The variable with the highest agreement between users was the anti-microbial options with a Fκ of 0.815 (95% CI 0.811 – 0.819) which correlated to an ‘almost perfect agreement’. Despite this, the classification of the more complex isolates proved problematic. The most variability was seen in the bone involvement variable with an Fκ of 0.479 (95% CI 0.475 – 0.483) which correlated to a ‘fair agreement’. Conclusions. The B.A.C.H. classification system for long bone osteomyelitis demonstrated a substantial agreement between observers according to the Fκ value. This was supported by a high level of accuracy of classification within each of the variables. The bone involvement category had a moderate agreement amongst users. This could be due to the nature of the 2-D presentation of cases within the online form. The Fκ was not influenced by clinical experience or clinical specialty, suggesting that B.A.C.H. is applicable by all levels. Further work is required to assess and optimise the descriptions of the bone involvement and anti-microbial options variables

The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used. From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation. 29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test. Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients. Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction

Grade III Open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. We reviewed medical notes of 73 patients with 74 Grade III Open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and b) those who had definitive treatment completed in < 72 hours vs. > 72 hours. Of subjects that underwent definitive fixation and coverage in a single procedure, 4.2% developed deep infections, compared with 34.6 % deep infection(p<0.001) in those who underwent definitive treatment at separate operations. Of patients who had definitive treatment completed in < 72-hours, 20.0% developed deep infections a compared with 12.2%(p=0.4919) in the >72-hour group. Patients with Gustilo III open tibial fractures have lower rates of deep infection if definitive fixation and coverage are performed in a single-stage procedure. Emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic surgery

We sought to evaluate the impact of a dedicated weekly ortho-plastics operating list on our ability to provide definitive soft tissue cover of open lower limb fractures within 72 hours. We reviewed all open lower limb fractures at our centre before and after the introduction of an ortho-plastics list to determine whether definitive soft tissue coverage was achieved within 72 hours. There were 23 open lower limb fractures at our centre in 2012 before the introduction of the ortho-plastics operating list of which only 7 (30%) had definitive soft tissue coverage within 72 hours. We hypothesised that the main reason for this was not patient or injury related factors but rather the logistical difficulties of coordinating theatre time on a routine trauma list with senior orthopaedic and plastic surgeon availability. To test this hypothesis we re-audited our time to soft tissue cover six months after the introduction of the ortho-plastics list and 70% of cases achieved coverage within 72 hours. Achieving definitive soft tissue coverage of open lower limb fractures within 72 hours of injury is a challenge. A dedicated weekly ortho-plastics operating list significantly improves our ability to deliver this service

This study presents an unusual recurrent case of pigmented villonodular synovitis (PVNS) around a ceramic-on-metal (COM) hip retrieved at 9-years. PVNS literature relates to metal-polyethylene and ceramic-ceramic bearings. Amstutz reported 2 cases with MOM resurfacing and Xiaomei reported PVNS recurring at 14 years with metal-on-polyethylene THA. Friedman reported on PVNS recurrence in a ceramic THA. Ours may be the first reported case of recurrent PVNS of a ceramic-on-metal articulation. This young female patient (now 38-years of age) had a total hip replacement in 2006 for PVNS in her left hip. In her initial work-up, this case was presumed to be a pseudotumor problem, typical of those related to CoCr debris with high metal-ion concentrations. She had an CoCr stem (AML), 36mm Biolox-delta head (Ceramtec), and a Pinnacle acetabular cup with CoCr liner (Ultramet, Depuy J&J). This patient had no concerns regarding subluxation, dislocation or squeaking. Three years ago she complained of mild to moderate groin and thigh pain in her left hip. This worsened in the past year. She noticed increased swelling now with an asymmetry to her right hip. She went to the emergency room in Dec-2014 and was referred to a plastic surgeon. In our consult we reviewed MARS-MRI and CT-scans that demonstrated multiple mass lesions surrounding the hip. Laboratory results presented Co=0.7, Cr=0.3 ESR=38 and Crp=0.3. At revision surgery, the joint fluid was hemorrhagic/bloody with hemosiderin staining the soft tissues. Multiple large 4–5×5cm nodules were present in anterior aspect of the hip as well as multiple nodules surrounding posterior capsule and sciatic nerve. Pathology demonstrated a very cellular matrix with hemosiderin-stained tissue and multiple giant cells, which was judged consistent with PVNS. The trunnion showed no fretting, no contamination and no discoloration. The superior neck showed impingement due to low-inclination cup. There was minimal evidence of metal-debris staining the tissues. There was a large metallic-like stripe across the ceramic head. This is a particularly interesting case and may be the first reported recurrent PVNS around a ceramic-on-metal bearing (COM). Data is scant regarding clinical results of COM bearings and here we have a nine-year result in a young and active female patient. She was believed to have a metalosis-related pseudotumor yet her metal-ion levels were not alarmingly high and there was no particular evidence of implant damage or gross wear products. In addition, the CoCr trunnion appeared pristine. Our work-up continues with analyses of wear and histopath-evidence. This case may demonstrate the need for a broadening of the differential diagnosis when dealing with hip failures

The purpose of this study is to report a unique overgrowth syndrome and discuss the insights into the complex orthopaedic management. Written consent to report this case was granted. The patient's condition, wrongly diagnosed as Proteus syndrome, is characterised by a genetic mutation in PIK3CA, a critical regulator of cell growth. This lead to unregulated cellular division of fibroblasts isolated to the lower limbs. The legs weighed 117 kg, with a circumference of >110 cm. In addition to lower limb overgrowth, numerous musculoskeletal and organ pathologies have been encountered since birth requiring treatment from a wide variety of healthcare specialists and basic scientists. At 32 years, the patient developed septicaemia secondary to an infected foot ulcer. Amputation had been discussed in the elective setting, however the presence of sepsis expedited surgery. The above knee amputation took 9 hours and four assistants including a plastic surgeon. A difficult dissection revealed a deep subcutaneous fatty layer that integrated with deep muscle, massive hypertrophy of cutaneous nerves and the sciatic nerve and ossification within the distal quarter of the quadriceps muscles requiring osteotomy. The lower limb osteology was grossly aberrant. The size of the amputated limb did not permit use of a tourniquet and cell salvage reintroduced 10.5 litres of blood with a further 6 units of red cells intra-operatively. The leg stump successfully took to a split-skin graft. A unique phenomenon was witnessed post-operatively whereby the stump continued to grow due to upregulation of fibroblasts secondary to trauma. Targeted genetic therapies have been successfully developed to suppress this stump growth. This unique and unclassified overgrowth syndrome was caused by a mutation in the PIK3CA gene. Orthopaedic management of the oversized limb was complex requiring multiple surgeons and prolonged general anesthetic. A multi-disciplinary approach to this condition is required for optimizing outcomes in these patients

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.

Aim. Chronic osteomyelitis still remains challenging and expensive to treat in spite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. Methods. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range 40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs). All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema and wound discharge. Primary outcome measure was resolution of infection. Results. All patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. Conclusions. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis

We present a series of 11 patients with infected tibial intramedullary nails which were treated at our tertiary referral centre from January 2000 to November 2009. All of them were males and the mean age was 36 years (26 to 47 years). All the patients had sustained post traumatic fractures which were treated with intramedullary nail. Four patients (36%) had sustained open fractures in whom adequate soft tissue cover was provided by plastic surgeons. Five of them (45%) were smokers. All of them underwent surgical debridement. Nine out of 11 patients had removal of metal work followed by one or more of the following procedures such as reaming, exchange nailing, excision of sequestrum, application of antibiotic beads and stabilisation with a frame with or without several bone grafts at a later date. Out of 11 patients six (55%) had no further episodes of infection, three (27%) still need short courses of antibiotics when the disease flares up and two (18%) underwent amputation. Causative organisms were isolated in all the patients. Commonest organism was MRSA. Overall, most of the organisms were sensitive to Vancomycin and resistant to Penicillin. Despite exploring most of the surgical procedures described for infected tibial intramedullary nails we have potentially eradicated infection only in about half of our patients. Hence we would like to emphasise that this condition still remains a serious problem and demands further insight in its management

Purpose. According to the National Institute for Clinical Excellence (NICE) a risk assessment for venous thromboembolism (VTE) should be conducted on all patients undergoing elective orthopaedic surgery. We looked at the patient outcome undergoing elective Ilizarov surgery in terms of symptomatic VTE occurring during or after frame management. Methods. We performed a retrospective chart review of all adult Ilizarov cases performed by a single surgeon between 2000–2011. Patient mortality was confirmed using the Demographics Batch Service. Results. There were 457 cases in 445 patients with a mean age of 42.6 years (range 16–84). There were 440 lower limb and 31 upper limb frames. 185 cases were for infection and 62 cases required flap coverage by plastic surgeons. There were 31 bone transports, 112 deformity corrections, 39 lengthening, 37 fusions, 48 stabilizations and 134 compression/distractions. The mean duration of frame treatment was 34 weeks (range 6–85). According to NICE guidelines all our cases had at least one risk factor for VTE; 243 had two, 200 had three and 28 had four or more. All cases received no pharmacological VTE prophylaxis (except 14 flap cases after 2009). There were three cases of VTE in two patients (one man with deep vein thrombosis and a 17 year-old girl with two pulmonary emboli). There were 23 deaths, all unrelated to VTE. The average cost of providing VTE prophylaxis according to NICE guidelines in this group would total £89,493.40 (£195.80 per patient). If only the first 28 days of frame treatment were covered the cost would be £14,231. Conclusion. Our reported incidence of VTE in Ilizarov surgery is low despite no pharmacological prophylaxis being used. This study challenges whether NICE guidelines are applicable to this particular group undergoing Ilizarov surgery

Infection after knee arthroplasty is a devastating complication. Our aim is to present our outcomes of treating infected knee replacements at a tertiary referral centre. We performed a consecutive, retrospective case series of all revision knee arthroplasty for infection between January 2006 and December 2008. Case notes were reviewed and data collated on the date and institution of primary arthroplasty, procedures undertaken at our institution, microbiology and bone loss post first stage, serological markers (C-reactive protein, ESR) prior to second stage and outcome. During this three year period we performed 430 knee revision operations. 51 were in the presence of deep chronic infection. 90% were referred from other hospitals. Overall infection was successfully eradicated in 69%. Nineteen patients underwent repeat two-stage and overall eleven (58%) patients had successful eradication of infection with multiple two-stages. Of these 47% had F3/T3, the highest grading of Anderson Orthopaedic Research Institute bone loss indicating no metaphyseal bone. A further 12% had bicondylar deficiency on the tibia and no femoral metaphyseal bone (F3/T2b). Multidrug resistance present in 69% and 47% were infected with multiple organisms. All members of the unsuccessful outcome group had at least one multidrug resistant organism compared to 43% in the successful cohort (P=0.0002). Multiple organisms are associated with an unsuccessful outcome (P=0.056). Serological markers were not significantly different between the successful and unsuccessful outcome groups. Where the referring hospital had attempted revision and failed, the chance of eradicating infection dropped from 75% to 58% and the rate of above knee amputation was twelve times higher (3% vs. 36%). Custom constrained, rotating hinge prostheses enable aggressive soft tissue debridement including ligaments. Successful two-stage requires a multidisciplinary approach including tissue viability nurses, microbiologists and plastic surgeons. Where units lack revision expertise this series suggests early referral increases the chance of limb salvage

We report our experience using a biodegradable calcium sulphate antibiotic carrier containing tobramycin in the surgical management of patients with chronic osteomyelitis. The patients were reviewed to determine the rate of recurrent infection, the filling of bony defects, and any problems with wound healing. A total of 193 patients (195 cases) with a mean age of 46.1 years (16.1 to 82.0) underwent surgery. According to the Cierny–Mader classification of osteomyelitis there were 12 type I, 1 type II, 144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3 to 7.1) with recurrent infection occurring in 18 cases (9.2%) at a mean of 10.3 months post-operatively (1 to 25.0). After further treatment the infection resolved in 191 cases (97.9%). Prolonged wound ooze (longer than two weeks post-operatively) occurred in 30 cases (15.4%) in which there were no recurrent infection. Radiographic assessment at final follow-up showed no filling of the defect with bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling in eight (4.4%). A fracture occurred in nine (4.6%) of the treated osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after operation.

We conclude that Osteoset T is helpful in the management of patients with chronic osteomyelitis, but the filling of the defect in bone is variable. Prolonged wound ooze is usually self-limiting and not associated with recurrent infection.

Cite this article: Bone Joint J 2014; 96-B:829–36