Aims

Chronic osteomyelitis may recur if dead space management, after excision of infected bone, is inadequate. This study describes the results of a strategy for the management of deep bone infection and evaluates a new antibiotic-loaded biocomposite in the eradication of infection from bone defects.

Revision arthroplasty after infection can often be complicated by both extensive bone loss and a relatively high rate of re-infection. Using allograft to address the bone loss in such patients is controversial because of the perceived risk of bacterial infection from the use of avascular graft material. We describe 12 two-stage revisions for infection in which segmental allografts were loaded with antibiotics using iontophoresis, a technique using an electrical potential to drive ionised antibiotics into cortical bone.

Iontophoresis produced high levels of antibiotic in the allograft, which eluted into the surrounding tissues. We postulate that this offers protection from infection in the high-risk peri-operative period. None of the 12 patients who had two-stage revision with iontophoresed allografts had further infection after a mean period of 47 months (14 to 78).

This paper outlines the history of advances made in the treatment of open fractures that have occurred during wartime.

We reviewed the clinical details and radiographs of 52 patients with ballistic fractures of the femur admitted to the International Committee of the Red Cross Hospital in Kenya (Lopiding), who had sustained injuries in neighbouring Sudan. In all cases there had been a significant delay in the initial surgery (> 24 hours), and all patients were managed without stabilisation of the fracture by internal or external fixation.

Of the 52 patients, three required an amputation for persisting infection of the fracture site despite multiple debridements. A further patient was treated by an excision arthroplasty of the hip, but this was carried out at the initial operation as a part of the required debridement.

All of the remaining 48 fractures healed. Four patients needed permanent shoe adaptation because of limb shortening of functional significance.

Although we do not advocate delaying treatment or using traction instead of internal or external fixation, we have demonstrated that open femoral fractures can heal despite limited resources.

A retrospective review was performed of patients undergoing primary cementless total knee replacement (TKR) using porous tantalum performed by a group of surgical trainees. Clinical and radiological follow-up involved 79 females and 26 males encompassing 115 knees. The mean age was 66.9 years (36 to 85). Mean follow-up was 7 years (2 to 11). Tibial and patellar components were porous tantalum monoblock implants, and femoral components were posterior stabilised (PS) in design with cobalt–chromium fibre mesh. Radiological assessments were made for implant positioning, alignment, radiolucencies, lysis, and loosening. There was 95.7% survival of implants. There was no radiological evidence of loosening and no osteolysis found. No revisions were performed for aseptic loosening. Average tibial component alignment was 1.4° of varus (4°of valgus to 9° varus), and 6.2° (3° anterior to 15° posterior) of posterior slope. Mean femoral component alignment was 6.6° (1° to 11°) of valgus. Mean tibiofemoral alignment was 5.6° of valgus (7° varus to 16° valgus). Patellar tilt was a mean of 2.4° lateral (5° medial to 28° lateral). Patient satisfaction with improvement in pain was 91%. Cementless TKR incorporating porous tantalum yielded good clinical and radiological outcomes at a mean of follow-up of seven-years.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):87–92.

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions.

Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis.

Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.

This study explores the relationship between delay to surgical debridement and deep infection in a series of 364 consecutive patients with 459 open fractures treated at an academic level one trauma hospital in North America.

The mean delay to debridement for all fractures was 10.6 hours (0.6 to 111.5). There were 46 deep infections (10%). There were no infections among the 55 Gustilo-Anderson grade I open fractures. Among the grade II and III injuries, a statistically significant increase in the rate of deep infection was found for each hour of delay (OR = 1.033: 95% CI 1.01 to 1.057). This relationship shows a linear increase of 3% per hour of delay. No distinct time cut-off points were identified. Deep infection was also associated with tibial fractures (OR = 2.44: 95% CI 1.26 to 4.73), a higher Gustilo-Anderson grade (OR = 1.99: 95% CI 1.004 to 3.954), and contamination of the fracture (OR = 3.12: 95% CI 1.36 to 7.36). These individual effects are additive, which suggests that delayed debridement will have a clinically significant detrimental effect on more severe open fractures.

Delayed treatment appeared safe for grade 1 open fractures. However, when the negative prognostic factors of tibial site, high grade of fracture and/or contamination are present we recommend more urgent operative debridement.

Cite this article: Bone Joint J 2014;96-B:379–84.

The October 2012 Spine Roundup³⁶⁰ looks at: a Japanese questionnaire at work in Iran; curve progression in degenerative lumbar scoliosis; the cause of foot drop; the issue of avoiding the spinal cord at scoliosis surgery; ballistic injuries to the cervical spine; minimally invasive oblique lumbar interbody fusion; readmission rates after spinal surgery; clinical complications and the severely injured cervical spine; and stabilising the thoracolumbar burst fracture.

We live in troubled times. Increased opposition reliance on explosive devices, the widespread use of individual and vehicular body armour, and the improved survival of combat casualties have created many complex musculoskeletal injuries in the wars in Iraq and Afghanistan. Explosive mechanisms of injury account for 75% of all musculoskeletal combat casualties. Throughout all the echelons of care medical staff practice consistent treatment strategies of damage control orthopaedics including tourniquets, antibiotics, external fixation, selective amputations and vacuum-assisted closure. Complications, particularly infection and heterotopic ossification, remain frequent, and re-operations are common. Meanwhile, non-combat musculoskeletal casualties are three times more frequent than those derived from combat and account for nearly 50% of all musculoskeletal casualties requiring evacuation from the combat zone.

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring.

As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases.

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union.

This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study.

The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time.

There have been many advances in the resuscitation and early management of patients with severe injuries during the last decade. These have come about as a result of the reorganisation of civilian trauma services in countries such as Germany, Australia and the United States, where the development of trauma systems has allowed a concentration of expertise and research. The continuing conflicts in the Middle East have also generated a significant increase in expertise in the management of severe injuries, and soldiers now survive injuries that would have been fatal in previous wars. This military experience is being translated into civilian practice.

The aim of this paper is to give orthopaedic surgeons a practical, evidence-based guide to the current management of patients with severe, multiple injuries. It must be emphasised that this depends upon the expertise, experience and facilities available within the local health-care system, and that the proposed guidelines will inevitably have to be adapted to suit the local resources.

Elastofibroma dorsi is an uncommon, benign, slow-growing soft-tissue tumour of uncertain aetiology. It classically presents as an ill-defined mass at the inferior pole of the scapula with symptoms which include swelling, discomfort, snapping, stiffness and occasionally pain.

We report the symptoms, function and outcome after treatment of 21 elastofibromas in 15 patients. All were diagnosed by MRI and early in the series four also underwent CT-guided biopsy to confirm the diagnosis. In all, 18 tumours were excised and three were observed. After excision, the mean visual analogue score for pain decreased from 4.6 (0 to 10) pre-operatively to 2.4 (0 to 8) post-operatively (p = 0.04). The mean shoulder function, at a mean follow-up of 4.2 years (3 months to 16 years), was 78.1% (30 to 100) using the Stanmore percentage of normal shoulder assessment scoring system. The mean range of forward flexion improved from 135° (70° to 180°) to 166° (100° to 180°) after excision (p = 0.005). In four patients a post-operative haematoma formed; one required evacuation. Three patients developed a post-operative seroma requiring needle aspiration and one developed a superficial infection which was treated with antibiotics.

Our findings support previous reports suggesting that a pre-operative tissue diagnosis is not necessary in most cases since the lesion can be confidently diagnosed by MRI, when interpreted in the light of appropriate clinical findings. Surgical excision in symptomatic patients, is helpful.

It has been suggested that elastofibroma is caused by a local tissue reaction and is not a true neoplastic process. A strong association has been noted between elastofibroma and repetitive use of the shoulder, which is supported by our findings.

Iontophoresis is a novel technique which may be used to facilitate the movement of antibiotics into the substance of bone using an electrical potential applied externally. We have examined the rate of early infection in allografts following application of this technique in clinical practice. A total of 31 patients undergoing revision arthroplasty or surgery for limb salvage received 34 iontophoresed sequential allografts, of which 26 survived for a minimum of two years. The mean serum antibiotic levels after operation were low (gentamicin 0.37 mg/l (0.2 to 0.5); flucloxacillin 1 mg/l (0 to 1) and the levels in the drains were high (gentamicin 40 mg/l (2.5 to 131); flucloxacillin 17 mg/l (1 to 43). There were no early deep infections. Two late infections were presumed to be haemotogenous; 28 of the 34 allografts were retained. In 12 patients with pre-existing proven infection further infection has not occurred at a mean follow-up of 51 months (24 to 82).