One of the most challenging complications in orthopedic trauma surgery is the development of infection. Improved infection prophylaxis could be achieved by providing local delivery of antibiotics directly to the tissue-implant interface. Especially implant-associated bone infections caused by antibiotic-resistant pathogens pose significant clinical challenges to treating physicians. Prophylactic strategies that act against resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA), are urgently required.

The objective of this experimental study was to determine the efficacy of a biodegradable Polymer-Lipid Encapsulation MatriX (PLEX) loaded with the antibiotic doxycycline as a local prophylactic strategy against implant-associated osteomyelitis in a humeral non-fracture rabbit model.

Activity of the PLEX-doxycycline-coating was tested against both a doxycycline susceptible (doxyS) methicillin-susceptible S. aureus (MSSA) as well as a doxycycline-resistant (doxyR) MRSA. In a rabbit intramedullary (IM) nail-related infection model, twelve rabbits received an inoculum of a doxyS MSSA direct into the medullary cavity of the humerus. After inoculation, animals received either a PLEX-doxycycline-coated nail, or an uncoated nail. The animals were observed for four weeks. Upon euthanasia, quantitative bacteriology was performed to determine bacterial load in tissues and biofilm formation on the implant. A second study was performed with sixteen rabbits receiving a DoxyR MRSA inoculum, again in coated and uncoated groups.

In vitro elution studies revealed that 25% of the doxycycline was released from the PLEX-coated implants within the first day, followed by a 3% release per day up to day 28. Quantitative bacteriology revealed the presence of osteomyelitis in all animals receiving an uncoated nail in both the MSSA and the DoxyR MRSA studies (figure). All rabbits receiving a PLEX-doxycycline-coated nail were culture negative in the doxyS MSSA-group and the surrounding bone displayed a normal physiological appearance in both histological sections and radiographs. In the doxyR MRSA inoculated rabbits, a statistically significant reduction in the number of culture-positive samples was observed for the PLEX-doxycycline-coated group when compared to the animals that had received an uncoated nail, although the reduction in bacterial burden did not reach statistical significance.

Improved prophylaxis against infection in trauma and orthopedic implant surgery is clearly required today. In this study, we investigated a PLEX-doxycycline-coated IM nail in a humeral non-fracture rabbit model. The PLEX-doxycycline coating on titanium alloy implants provided complete protection against implant-associated MSSA osteomyelitis, and resulted in a significant reduction in the number of culture positive samples when challenged with a doxycycline-resistant MRSA.

Purpose

Gustilo type III open fractures are associated with high infection rates in spite of instituting a standard of care (SOC) consisting of intravenous antibiotics, irrigation and debridement (I&D), and delayed wound closure. Locally-delivered antibiotic has been proven to assist in reducing infection in open fractures. The aims of this study are to determine the effectiveness and safety of a new implantable and biodegradable antibacterial product¹ in preventing bacterial infections and initiating bone growth in open fractures.

Introduction: Plantar fasciitis is a common syndrome characterized by pain at the origin of the plantar fascia, most often on rising after a period of inactivity. It is usually self limited. Treatment includes: NSAIDs, physical therapy, orthotics, steroid injections, and lately shock wave therapy. Patients who fail to respond to non-operative treatment are often referred to one of a variety of surgical procedures.

We report our experience with one such procedure, percutaneous release via a medial approach.

Methods: At our institution, patients with plantar fasciitis who fail to improve despite first (NSAID, PT) and second (injection, orthotics) line therapy, are referred for percutaneuos plantar fasciotomy. We retrospectively reviewed 34 patients who underwent 38 procedures between 1999–2006. Mean patient age at surgery was 50 (30–65). 24 were evaluated by an uninvolved orthopedic surgeon at an outpatient clinic, and 10 responded to a mail or telephone questionnaire. Assessment included pain relief, functional improvement, complications, and willingness to re-undergo, or recommend the surgery.

Results: Average VAS score dropped from 8.9 to 2.1. Function improved in 93%. The surgery met or exceeded expectations in 76%, and 82% would have re-undergone or recommended the procedure. Injury to the lateral plantar nerve was encountered in 3 patients.

Conclusion: Percutaneous plantar release is an effective treatment for resistant plantar fasciitis. Care should be taken to prevent nerve injury by accurate technique.

Introduction: Total hip arthroplasty preformed with the use of minimal incision surgery has received tremendous attention recently. Various surgical approaches have been introduced to minimize surgical trauma to the soft tissues. The mini invasive Modified Watson-Jones approach have been selected to decrease the perioperative complications associated with other mini invasive approaches that has been described.

The anterolateral mini incision is a new innovative approach using the intramuscular plan between the gluteus medius and the tensor fascia lata. This intermuscular interval through a small incision provides good exposure and preserves muscle integrity. Moreover, preserving the muscle integrity provides a very stable joint after implantation such that no restrictions is giving to the patient during the rehabilitation period.

Materials and Methods: Between July 2004 to September 2005, we used this approach on 60 sequential patients. Fifty patients were enrolled in this prospective study. Patients were evaluated preoperatively, immediately postoperatively, and at 3-month and 6 month follow-up according to operating time, intraoperative blood loss, subcutaneous drains blood loss, post op pain control drugs requirements, short form 36 patient questionnaire (SF-36) scores and the Harris Hip Score (HHS). 4 patients had previous THA on the contralteral side.

Results: The average operation time was 137min (range 90–200min), there were no dislocations, the mean post operation blood transfusion requirements was 1.64, the mean subcutaneous drains blood loss was 241.9ml (range 20–620ml), there was significant improvement in function, pain, SF-36 and Harris Hip Score (HHS) at the 3-month and 6-month follow-up examination. The average length of the incision was under 12cm. We had one reoperation due to deep infection. All four patients with bilateral THA preferred their last operation due to lack of post operative restrictions and due to shorter recovery of muscle strength.

Conclusion: We think that using mini invasive Modified Watson-Jones approach in total hip replacement surgeries is a preferable option. There are several advantages of using this approach compared with the more traditional techniques. Such a technique should help reduce morbidity and complication rates for those patients undergoing a total hip replacement.

Introduction: Non union of the humerus in the ostoeportic bone is a great challenge for the orthopedic surgeon. The non weight bearing nature of this bone together with extreme osteoporosis seen in the elderly had rendered a high degree of failure in different modes of internal fixation of established humeral non union. Tantalum is a trabecullar metal with biomechanical properties similar to bone with a high modulus of elasticity and low rigidity. It is proved both in vitro and in vivo to induce excellent bone and vascular in growth and have been used successfully treating other application in orthopedics. We have introduced the tantalum rod for the treatment of humeral non union in the elderly.

Patients and Methods: Six patients with humeral non-union were selected for tantalum rod implantations. All were above 60 years old. All patients had established non and 4 had failures after previous osteosynthesis. The surgical technique was exploration of the fracture site via a posterior or an anterolateral approach, debridement of the fracture site and intramedullary insertion of a 100 mm x 10 mm tantalum rod. No bone grafting was used. Ancillary fixation included a 4.5 broad DCP plate with screws drilled into both bone and rod or screws alone drilled into the bone and tantalum construct. Follow up period was up to one year.

Results: All fractures united clinically and radiographicaly up to 3 months. All patients achieved satisfactory shoulder and elbow range of motion and regained functional activity. No infection or foreign body reaction was noted.

Conclusion: Intramedullary tantalum rodding is a viable treatment option for the cases in both primary and secondary non union of the humeral shaft in osteoporotic bone.

Introduction: Osteolysis is a significant problem associated with hip replacement. In the early stages of osteolysis, when the implant is still stable, formal revision is technically demanding and may result in signififant bone loss. A recently described technique for acetabular component revision addresses osteolysis, retaining the acetabular cup and cementing a new polyethylene liner.

Materials and Methods: Between January 2000 and December 2003, 29 liner cementation revisions in 27 patients were performed. The mean age was 61 years (range 37–77), the mean time elapsed after the original surgery was 6.7 years (3–14). 23 of the hips (79%) were ABG (Howmedica). Only 20 (69%) of the patients were clinically symptomatic. At surgery the polyethylene was removed and osteolytic cysts were debrided. Then, the metal acetabular component was tested for stability. Obviously, only stable metal implants were not revised. The cysts were filled with bone graft or bone substitute and a new polyethylene liner was cemented in with methylmetacrilate augmented gentamicin. The patients were evaluated by modified Harris Hip Score (HHS) and by SF-12 score. The mean follow up was 25 months (10–45).

Results: The average HHS was 86/4 and its pain component was 38.8. The average physical component of SF-12 was 45.9 (19.5–57.2) and the average metal component was 54.6 (29–66.9). The post-operative HHS and the SF-12 scores were high (good or excellent) in all patients reflecting good clinical outcome. In patients who were asymptomatic prior to surgery, both the HHS and the pain score were significantly higher compared to the symptomatic patients (p< 0.01). One patient with extensive bone loss needed revision surgery due to early postoperative fracture of the acetabulum, and another patient had recurrent dislocations that required revision.

Summary: We conclude that revision of the polyethylene liner and cementation of a new one is a safe and useful technique in patients with stable acetabular shell. This is especially true for asymptomatic patients with osteolysis.

We tested the hypothesis that it is possible to accelerate fracture healing by changing the mechanical environment used in current methods i.e., from initial rigidity or micromovement followed by dynamisation to initial macromovement followed by rigidity (micro-movement).

It is accepted that callus formation requires movement at the fracture site and this callus response is limited to the first few weeks after fracture. Logically, early macromovement at the fracture site would be beneficial for callus formation. Additional callus is not produced by further movement. Indeed, it may be counter-productive, just as continuing movement around two ends of a wooden stick bonded with glue will retard and even prevent “union”. We postulate that continuing movement at the fracture site after the callus response has ceased will also delay union. As a result, rigidity rather than dynamisation is required in the later stage of fracture healing.

After testing an animal model, we built an external fixator which allowed 5 mm of axial movement without “self-locking” and could be compressed at a later date in order to prevent further movement.

A trial containing 15 patients with unilateral tibial shaft fractures (closed or grade 1 open) was undertaken after permission was obtained from the Helsinki Ethical Committee.

So far, 13 patients have been entered into the trial. They have completed therapy and are at least one year post-fracture (12 months to 22 months). Age range is from 20 to 49. The group is composed of nine males and one female.

Under general anaesthetic, an external fixator was applied and the fracture reduced. The patients started ankle exercises (active and passive) the following day, with as much weight-bearing on the fractured leg as possible on the day after. The patients were seen every two weeks and AP and lateral radiographs were taken. The fracture was compressed two to six weeks later. The percentage of body weight that the patient was able to tolerate through the fractured limb was measured by using the scales of Meggit’s step test. The fixators were removed when there was radiographic union and the patient could take at least 80% of body weight through the fractured limb. Mean time duration up to removal of the fixator was 10.8 weeks (range 7 to 15.4 weeks).

We conclude that it is possible to increase the speed of bone healing by changing the mechanical environment to initial macromovement followed by elimination of movement.

A consecutive series is reported of 17 patients who underwent early surgical treatment for acetabular or unstable pelvic fractures associated with ipsilateral fractures of the femur. Treatment included external and internal fixation, and required careful consideration of the surgical approach and the positioning of the patient. The multiple injuries sustained by these patients required simultaneous procedures by several surgical teams. All the femoral fractures were internally fixed at the initial operation and eight patients had primary definitive treatment of all their other fractures as well. In nine patients the definitive treatment of their other fractures was delayed for an average of 11 days. There were no deaths, and no serious infections. The long-term morbidity resulted from the associated injuries and not from the pelvic or femoral fractures.

Split-thickness skin excision can be used as a one-stage procedure for the accurate diagnosis of flap viability and the immediate treatment of friction-avulsion injuries in severe open fractures. After cleaning the wound, the avulsed flap is temporarily sutured back to its original bed and a split thickness graft is taken from it and meshed to a 1:3 ratio. Surface dermal capillary bleeding then serves as an indicator of viability, clearly displaying a line for the excision of devascularized skin and correlating well with a concomitant fluorescein test. The wounds are re-opened and, after fixation of the fracture, the viable part of the flap is returned to its original bed and the remaining defects are covered with the meshed graft. We have treated 16 patients with extensive degloving injuries in this way, 15 needing only the single surgical procedure. All retained flaps survived, no other donor sites were needed and the split-thickness grafts took with 90% to 100% success.