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.

Aim

Posttraumatic pelvic-osteomyelitis is one of the most serious complications after pelvic-fractures. The necessary extensive surgical debridement as part of interdisciplinary treatment is complicated by the possible persistence of pelvic instability. The aim of this study was to determine the outcome and outline the course of treatment after early posttraumatic pelvic bone infections due to type-C pelvic ring injuries.

Aim

Prosthetic joint infections (PJI) after failed knee arthroplasty, especially in complicated courses with persisting or recurrent infections, may result in a considerable destruction of bone substance, the extensor apparatus and the surrounding soft tissue. In these cases reconstruction of a proper knee function may be impossible and the only solutions are: knee arthrodesis or above-the-knee amputation (AKA). However, both methods are associated with considerable functional deficits and high complication rates. The primary aim of the current study is to analyse the clinical course, outcome and complications in patients with knee arthrodesis and AKA after PJI and to compare these two methods in terms of the analysed parameters.

To prevent nosocomial transmission (NT) of multiresistent germs (MRG) the German Robert Koch Institute (RKI) recommends to isolate patients with MRG.

At a so-called normal ward isolating patients is a challenging and stressful procedure for both patients and hospital staff.

The present study proposes the hypothesis that, compared to normal wards, an isolation ward reduces the nosocomial infection rate.

After an isolation ward with twelve beds has been established in 2005, patients with MRG on the wards of the department for spinal cord injury as well as on the isolation ward were monitored using a prospective screening and meeting the requirements of the RKI. Apart from detecting transmitter of MRG the NT of these bacteria was identified and registered between 2006 and 2013.

The total length of a patients stay in the hospital, the number of isolation days and the rate of NTs were documented. The quotient of MRG load per ward and the number of NTs per ward were compared.

In the investigation period of eight years 262175 patient days, 33416 isolation days and 33 transmissions were registered.

On the spinal cord injury ward 223167 of the patient days, 1120 of the isolation days and 29 of the NTs were documented. On the isolation ward 39008 of the patient days and 32296 of the isolation days with four of the transmissions were registered.

The mean load of MRG resulted from the quotient of the number of days with MRG per 100 patient days.

The effective nosocomial frequency of transmission resulted from the quotient of the mean load of MRG to the number of transmissions.

As a result, the frequency of transmission on the isolation ward was significantly lower (p=0,001) in comparison to the spinal cord injury ward.

The presented results suggest that, despite multiple higher loads of MRG, constructional measures combined with contact isolation facilitate a reduction of NT rates of MRG.

The reservation must be made, however, that in case of known MRG the screening was performed under isolation conditions, with unkown MRG without meeting requirements of isolation.

The present comparison of NT rates on an isolation ward and a normal spinal cord injury ward emphasizes the importance and function of an isolation ward through constructional (physical) separation and pooling of professional competency for successful management of MRG in healthcare facilities.

Of the 6075 patients enrolled in EU-CORE registry, 206 patients had orthopaedic device-related infections. Significant underlying diseases were reported in 71% patients, most frequently cardiovascular disease (38%). The common sites of infection were knee (40%) and hip (33%). Among the 170 patients with available culture results, 135 (79%) were positive. Coagulase-negative staphylococci (CoNS, 44%) and Staphylococcus aureus (43%, of those 47% were methicillin resistant) were the most commonly isolated pathogens. Daptomycin was used empirically in 48% patients and as second-line therapy in 67% patients. During daptomycin therapy, 67% patients had undergone surgery (debridement, 61%; removal of foreign device, 39%; incision and drainage, 9%). Over half of the inpatients (54%) received concomitant antibiotics. Daptomycin was most frequently prescribed at a dose of 6 mg/kg/day (48%), with a median duration of therapy of 16 (range, 1–176) days. The overall clinical success rate was 85%, and was similar whether daptomycin was administered as first- or second-line therapy. The success rates achieved for infections caused by S. aureus and CoNS were 86% and 83%, respectively. Among the 79 patients who entered the long-term follow-up, 85% had a sustained response. Adverse events (AEs) and serious AEs possibly related to daptomycin were reported in 4.4% and 1.9% patients, respectively.

Results from this real-world clinical experience showed that daptomycin is an effective and well-tolerated treatment option for orthopaedic device-related infections with a high success rate up to 2 years of follow-up.

Objectives: Goal of this retrospective study is to evaluate risk factors, which lead to an osteitis of the tibia depending on the fracture location.

Methods: The study was initiated 01/2002. The study population consists of 104 patients including 14 women (13%). All of them suffered from an osteitis of the tibial. All of them are complications after traumatic open or closed fractures of the tibia, treated surgical. The average age of the patients has been 48 (± 18) years. In 28 cases there has been an acute osteitis of the tibia. In the other 76 patients the infection was not noticed before the ninth week after trauma. In all patients the risk factors were analyzed depending on the fracture configuration, the soft tissue situation, and the fracture location.

Results: All infections have been localized at the fracture level. The majority of the patients suffered from open tibial fractures (77.4%). 7.9% have been first, 23.6% second, and 68.5% third degree open fractures. Almost half of the fractures (48.1%) were located at the distal third of the tibia. Equally, 25.9% of the infections were localized in the medial and proximal third of the tibia. The percentage of open fractures leading to an osteitis was significant highest (p < 0.01) at the medial third of the tibia (91.3%), whereas the percentage of open proximal fractures has been 61.1% and open distal fractures 62%. The complexity of the fractures of the proximal, medial, and distal third of the tibia was very similar. The proportion of osteosynthesis with fixateur externe, plating, or naling showed no significant differences. 37.8% of the patients were smoker. The percentage of smoker was significant highest (p < 0.05) in the subgroup osteitis after closed tibial fracture (69.9%). The number of the other risk factors (Diabetes mellitus, hypertension, alcohol consumption, adipositas, PAD) was similar in all subgroups. There have been no differences between the 28 acute versus the 76 chronic osteitis.

Conclusion: The majority of the posttraumatic tibial osteitis is localised in the distal third. The most important risk factor for the development of a posttraumatic tibial osteitis is the dimension of the soft tissue defect. This is particularly true for the medial third of the tibia where the percentage of open fractures is significant highest. Additionally nicotine consumption is a major risk factor for the development of a posttraumatic tibial osteitis, particularly in cases of closed distal tibial fractures.

Objectives: An osteitis of the tibia remains a major problem especially in cases of open tibial fractures. A successful therapy management goes along with a radical bacterial eradication, sufficient soft tissue coverage, and a stable osseous reconstruction.

Methods: The study population consists of 112 patients (53 ± 13 years). All of them suffered from a tibial osteitis after fracture of the tibia. The study population was divided in patients with osteitis after open versus non open tibial fracture. The therapy strategy was the same in both groups. It was done according to a standardised treatment plan including radical surgical eradication of infectious and necrotic tissue, programmed lavage with vacuum sealing in combination with an effective bacterial antibiotic therapy. Surgical stabilization was done in cases of instability. Final osseous reconstruction and soft tissue coverage was performed if necessary after three negative intraoperative smears.

Results: 89 patients of the patients (79%) suffered form open tibial fractures versus 23 (21%) patients with non open fractures (NOF). The average inpatient treatment time was 13 ± 18 weeks in cases of osteitis after open tibial fractures and 8 ± 4 weeks after NOF. The average number of operative procedures after open fractures vs NOF was 10 ± 7 vs 8 ± 4. In 55 patients a muscle flap procedure was performed after open tibial fractures (53%) versus 9 (26%) after NOF. An amputation of the lower leg had to be done in 5 patients after open tibial fractures (5%) versus in 2 patients after NOF (6%). The rate of bacterial eradication with no recurrence of infection for at least one year was 53% in cases of osteitis after open tibial fracture and 65% after NOF.

Conclusion: An open fracture of the tibia is a major risk factor for developing a chronic osteitis. The eradication of bacterial infections takes a longer time and more operative procedures are necessary in cases of open tibial fractures versus closed fractures. In cases of open fractures there exists a higher need of soft tissue reconstruction by muscle flaps. After eradication there are no significant differences in the one year recurrence rate.

Necrotizing fasciitis is a definition of a specific histopathology, the pathogenesis and clinical features vary broadly. Symptomatically is the severe invasive infection of the soft tissues with high rates of patient morbidity and mortality. Beside the most common identified bacteria as A Streptococci (GAS), other bacteria are identified such as gram-positive or-negative bacteria or mixed infections. The aim of the following study was to analyze the specific predisposing risk factors and outcome of patients suffering necrotizing fasciitis.

Methods: The data of patients suffering necrotizing fasciitis were prospective collected since 2004. Criteria were the clinical and histological evidence of a necrotizing fasciitis. The clinical course, concomitant diseases, detectable bacteria and outcome with focus on limb salvage, amputation rates and hospital mortality was analyzed. Primary focus of the therapeutic regimen was the surgical and intensive care therapy. Adjuvant therapy was the hyperbaric oxygen therapy.

Results: 55 patients were prospective enrolled in the study with the clinical and histological diagnosis of a necrotizing fasciitis from 2004–2008. The mean age of the patients was 58 ± 15 years at the timepoint af admission to the hospital. Gender distribution was 68 % male and 32 % female. 87 % of these patients were admitted after interhospital transfer. 82 % were admitted to the intensive care unit and 78 % needed catecholamines. The hospital mortality was 31 %. The ranking list of potential risk factors in descending frequency was: diabetes, obesity, immunosupression of different causes. Affected were in 22 % of the cases the upper extremities, 72 % lower extremities and/or in 12 % the trunk. In 80 % of the deceased patients the pelvic region or the trunk was involved. Almost half of the patients suffered an amputation of one limb.

Summary: The necrotizing fasciitis remains an interdisciplinary challenge for specialized centers providing the logistical infrastructure for the treatment of these patients. Despite the optimal treatment options and additional therapy with hyperbaric oxygen therapy the hospital mortality remains high. Prognostic unfavorable is the involvement of the trunk and pelvic region. Typical risk factors are described above. The analysis of pathogenic bacteria shows a broad variety and gives no clear hints in the diagnosis or prognosis of the fasciitis. Crucial for the surgery and indication for limb amputations as a salvage procedure is the clinical course.

Our question is whether it is possible, by means of (18)F Fluorodesoxyglucose-Positron-Emission-Tomography-Computertomography (FDG-PET-CT) data created in line with the diagnostics of chronic osteitis, to undertake a navigation for the treatment of the focus of osteitis.

Within the scope of an experimental examination, the focus of osteitis at an animal bone model (pork) has been simulated. The animal bone was prepared with injection of FDG via three 2.5 mm drill holes into the bone marrow. For further investigation the FDG was injected undiluted, mixed with pigment and with radiopaque contrast medium.

Using FDG, a PET-CT dataset at the primed animal bone model has been created. For matching the position of the artificial FDG-focus and the virtual displayed position two cortical screws were placed close to the FDG-focus in the cortical bone. Two X-Ray shots in different positions were taken from the region of interest. The referencing of the dataset was achieved with CT-fluoro-matching. Finally, the accuracy of the image of the navigated instrument on the navigation display has been compared with the optical controlled actual placement of the simulated position of the focus of osteitis. The bone was sawed for the final check of the position of the FDG spot in relationship to the anatomical landmarks.

The examination demonstrated that with the available navigation system a PET-CT dataset could be identified. The matching of the CT-dataset with the geometry of the animal bone model was realised with CT-fluoro-matching software.

The verification of the image accuracy on the navigation screen did not show any deflection of the actual placement of the navigated instrument, because the position of the simulated focus of osteitis through the drilled canal was known. The experimental examination described above showed that PET-CT data can be imported into a conventional optical navigation system and can be edited for referencing purposes. It was possible to match the CT-dataset with the fluoroscopic images of the image intensifier. The optical verification of the accuracy did not show any deflection of the displayed position of the navigated instrument compared to the actual placement of the simulated focus of osteitis. The investigation shows sufficient threshold of the animal bone for visualisation with the navigation system.

Since the PET-CT data provide evidence about the activity of a pathological focus, in addition to the information about localisation, the navigated rehabilitation of foci of osteitis in long hollow bones appears possible. For successful treatment and salvage of chronic osteitis the implementation of navigated surgical tools can reduce the dimension of the surgical approach and damage of bone without reduction of the surgical goal.

Further clinical applications must determine whether the possibilities established experimentally can be implemented effectively in practice.

Objectives: This study evaluates the number of recurrence of acute infection following total knee arthroplasty treated with a concept of implant salvage using programmed revision surgery and specific long-term antibiotic therapy with and without additional application of antibiotics penetrating bacterial biofilms like rifampicin.

Methods: In a retrospective study, 24 patients with early infection of unconstrained total knee arthroplasty were treated according to our protocol and were followed up for a period of 4 years [range 1,2–6,2]

using a questionnaire to investigate course of disease and health-related quality of life (VAS). 7 patients were treated with and 17 patients without additional application of antibiotics penetrating bacterial biofilms.

Results: In the group of patients treated without additional application of antibiotics penetrating bacterial biofilms 11 of 17 (65%) implants were salvaged. In 5 cases revision arthroplasty and 1 arthrodesis were necessary to eradicate infection. Health-related quality of life and function of the arthroplasy were superior in the group of salvaged implants.

In the group of patients treated with additional application of antibiotics penetrating bacterial biofilms 6 of 7 (86%) implants were salvaged and reduced number of revison surgery was needed.

Conclusion: Treatment of infection with implant salvage may be one therapeutic option if the implant is not loose. Therapy with retention of the prosthesis may be indicated: in the case of early infection (< 3 weeks of ongoing symptoms), with unconstrained implants, in the case of infection by a single organism that is susceptible to antibiotic therapy, if soft tissue envelope is not affected, and if the immune system is not compromised. Early and consequent therapy with operative debridements and specific long-term antibiotic therapy are necessary to achieve implant salvage. Additional application of antibiotics penetrating bacterial biofilms such as rifampicin contribute to improve prognosis.

Due to the fact that revision arthroplasty is often associated with limited function after infection of total knee joint, retention of the implant has to be considered a therapeutic alternative in early infection.

Goal Is Positron Emission Tomography (PET) with [18F] fluordesoxyglucose (FDG) a suitable procedure in diagnostic of osteitis?

Method In a prospective clinical study from 02/2000 until 05/2004 we observed 120 patients with osteitis. The average age was 46 years, the relationship between female and male 1: 3 (31 female, 89 male). The PET was performed under the question of a posttraumatic osteitis. In cases of operative revision procedures bacteriological examinations were carried out

Results In 73 cases (61%) the PET showed positive findings. Surgical revision was carried out in 57 of these 73 patients (78%). The bacteriological findings in this cases were positive in 59% (n=34). Most of the proved germs were St. aureus in 53%, followed by St. epidermidis in 17%.

In the group of patients with negative findings in the PET (n=47) in 17 cases (36%) an operative procedure was carried out. The bacteriological findings were negative in 12 cases (70%). St. epidermidis was found in 4 cases with positive bacteriological findings.

Conclusion In our opinion the PET seems to be a valuable complement in the spectrum of diagnostically possibilities in connection with osteitis. Despite the low level of specifity in this study one of the great advantages is the visualization of the hot spot in a third plane. So the planning and carrying out of the surgical revision procedure can be improved. To increase the specifity of the PET in connection with the treatment of osteitis further research is required.

Purpose: Chronic posttraumatic osteomyelitis of the femur is still a great challenge for medical treatment. Bacterial colonization after multi-fragment fractures often complicates and extends bone healing. Muti-modal management including hyperbaric oxygenotherapy and frequent lavage and debridement as well as use of systemically and locally applied antibiotics are needed to eradicate infection.

This study introduces our treatment regime for chronic posttraumatic osteomyelitis of the femur and presents our results.

Material and Method: We reviewed 24 patients with posttraumatic osteomyelitis after femoral shaft fractures treated at our trauma center. We analyzed the bacterial spectrum, changes in bacterial spectrum during treatment, numbers of operative revisions and hyperoxygenotherapy cycles, as well as over all hospitalisation time, and outcome concerning bone healing.

Results: Staphylococci were the most frequently found bacteria at first revision, followed by Enterobacter species. Average length of treatment was 8.3 (1–29) months.

An average of 11.5 (2–32) operative revisions including intramedullar debridement were performed, additionally 10 patients underwent a mean of 29 (3–81) hyperoxygenotherapy cycles.

Re-Infection after treatment occured in 7 cases, in 2 patients amputation was needed to eradicate infection.

Conclusions: Our results show, that the chronic post-traumatic osteomyelitis of the femur is an insistent disease that needs to be treated interdisciplinary over a long period of time. Our treatment regime produces satisfying results. Individual solutions are necessary to reach an infection-free status.