Treatment of chronic osteomyelitis with antibiotic-impregnated polymethyl methacrylate (PMMA) – the Cierny approach: is the second stage necessary?

Background Chronic osteomyelitis is a challenge for orthopedic surgeons. Most patients with osteomyelitis receive two-stage management according to Cierny-Mader. The first stage includes radical debridement and insertion of an antibiotic-impregnated cement spacer (ACS) (beads, rods, nails, or blocks) into the bone defect. The second stage is performed 6–8 weeks later, when the spacer is removed and a cancellous autograft is placed within the bone defect. The possibility of ACS as definitive management for osteomyelitis, avoiding the second stage, is presented. Methods Sixteen patients with osteomyelitis received radical debridement and insertion of an ACS in all forms into the bone defect as a definitive management. In 8 patients, the tibia was infected, 4 had femur infection, 2 humerus, 1 fibula, and 1 ankle. The mean age at the time of the first stage of reconstruction was 49 years (range, 13–71 years). According to the Cierny-Mader classification, 1 patient was C-M IA, another was IB, 7 IIIA, 6 IIIB, and 1 was 4A. All B hosts had systemic illnesses. The mean follow-up period was 6 years (1.5–16 years). Results No patient exhibited radiographic evidence of excessive bone loss. Signs of recurrence of osteomyelitis were not noted in any of the patients, and no fractures had occurred by the last follow-up. Conclusion Our study suggests that a proportion of patients with planned retention of ACS appear to function well without requiring further surgical intervention, especially in elderly or vulnerable patients.

Masquelet technique in management of infective non-union of long bones- A prospective study

Introduction and Aim: Masquelet’s technique is a 2-staged procedure, for treatment of infected segmental bone defect. 1st stage involves radical debridement with antibiotic-induced cement spacer. During second stage, the spacer is removed and the autologous bone graft is applied into the biomembrane formed. In this study, we evaluate the Masquelet’s technique for the management of infective non-union of long bones. Materials and Methods: 15 patients with infective non-union of long bones- tibia, femur and a case of congenital pseudoarthrosis of tibia, were treated with Masquelet’s technique. They underwent 2 stages of procedures 6-8 weeks apart and was followed up for about 9 months and radiological and clinical outcomes were assessed. Results: Out of 15 patients with infective non-union, 8 patients attained union. Out of the 7 patients with failure of the technique, higher failure rates were attributed to Pseudomonas infection. Conclusion: Masquelet’s technique is a cost-effective method for treating infective segmental non-unions, not requiring special training or sophisticated instruments. This method shows good results with Gram positive infections. Although, the outcome with Pseudomonas aeruginosa infection, have not shown satisfactory results.

Mucormycosis in burns: a review

Mucormycosis is a rare fungal infection with a high mortality rate. It presents with scattered black/necrotic ulcers, white fungal elements, and progression of wounds despite seemingly adequate debridement. Diagnosis is confirmed on wound histology, however this is often delayed. There is currently no comprehensive review of burn related mucormycosis within the literature, making this the first paper to provide evidence-based treatment guidance. We performed a review of publications from 1946 - present. There were 151 cases of mucormycosis complicating burns. The mortality rate was 54.5%, and there was a significant increase in mortality with axial body site involvement compared with isolated peripheral involvement. The standard treatment was prompt and radical debridement. Utilisation of frozen section to guide debridement aided in clinical decision making. No systemic treatment reached statistical significance, however amphotericin B trended towards significance. Although there is no strong evidence for topical amphotericin B or hyperbaric oxygen, there may be benefit in some cases. This study recommends early radical debridement in conjunction with the European Confederation of Medical Mycology guidelines of IV liposomal/lipid complex amphotericin B >5mg/kg/day, with posaconazole 800mg daily in divided doses as a salvage or oral step-down 1.

A Hybrid Technique to Treat Inguinal Wound Infection after Arterial Surgery with Lateral Femoral Bypass and Intra-Incisional Negative Pressure Wound Therapy

Background: Patients with the inguinal wound infection after arterial surgery remains clinical challenge. Sustaining lymphatic leakage have been shown as a common and potentially serious complication. However, it remains clinical challenge for surgery to deal with this tough problem. Methods: This study describes a hybrid technique of using radical debridement, lateral femoral bypass (LFB) and intra-incisional negative pressure wound therapy (iNPWT) for single-staged treatment of complex inguinal wound infection after arterial surgery (IWI-AS).Results: Between January 2017 and June 2021, 5 IWI-AS cases treated with this new method were identified. Of the patients, 3 were males and 2 were females. The average age was 49.4 years (range, 33 to 77 years). 4 cases suffered emergent operations due to the sudden bleedings. after vascular bypass reconstructions and an average of 2.2 (range:1-3) iNWPT, all cases achieved wound healing at an average duration of 4.6 weeks (range: 3-6weeks). Moreover, all cases showed no bacterial growth and grafts patency as indicated by doppler ultrasound or CT angiography postoperatively. One case did not receive bypass imaging evaluation at postoperative 12 months. Weakness of quadriceps femoris was observed in one case. Conclusion: single-staged therapy of LFB and iNPWT hybridization is a technically handy and effective method for treatment of inguinal wound infection after arterial surgery.

Fabrication of antibiotic-loaded dissolvable calcium sulfate beads: an in vitro mixing lab utilizing various antibiotic mixing formulas

Chronic periprosthetic joint infection (PJI) is a devastating complication that requires an aggressive eradication protocol. Local antimicrobial delivery via dissolvable calcium sulfate (CaSO4) using small-sized beads (3–8 mm) has been utilized as an adjunctive treatment combined with implant exchange, radical debridement, and antimicrobial loaded acrylic spacers. The non-exothermic setting of CaSO4 theoretically allows for any antimicrobial agent to be used, so long as mixing methods provide a consistent fabrication within a reasonable set time. This study performed the first in vitro mixing study, in which various antimicrobial agents, used singularly and in combination, were mixed with a synthetic CaSO4 product to observe and document their interactions. The study was performed in a simulated operating room environment. We report a standard mix formula with set times, testing 22 different antimicrobial agents, combinations, and doses. For some antimicrobials and combinations, set times using the standard formula were either too fast or exceedingly slow. For these 14 antimicrobial agents and combinations, we were able to arrive at individualized mixing methods. We present all mixing formulas and set times. In all, we were able to establish mixing methods that incorporate all antimicrobial agents and combinations that we have seen utilized via surgeon-directed use.

A Hybrid Technique to Treat Inguinal wound Infection after Arterial Surgery with Lateral Femoral Bypass and Intra-incisional Negative Pressure wound Therapy

Background: Patients with the inguinal wound infection after arterial surgery remains clinical challenge. Sustaining lymphatic leakage have been shown as a common and potentially serious complication. However, it remains clinical challenge for surgery to deal with this tough problem. Methods: This study describes a hybrid technique of using radical debridement, lateral femoral bypass (LFB) and intra-incisional negative pressure wound therapy (iNPWT) for single-staged treatment of complex inguinal wound infection after arterial surgery (IWI-AS).Results: Between January 2017 and June 2021, 5 IWI-AS cases treated with this new method were identified. Of the patients, 3 were males and 2 were females. The average age was 49.4 years (range, 33 to 77 years). 4 cases suffered emergent operations due to the sudden bleedings. after vascular bypass reconstructions and an average of 2.2 (range:1-3) iNWPT, all cases achieved wound healing at an average duration of 4.6 weeks (range: 3-6weeks). Moreover, all cases showed no bacterial growth and grafts patency as indicated by doppler ultrasound or CT angiography postoperatively. One case did not receive bypass imaging evaluation at postoperative 12 months. Weakness of quadriceps femoris was observed in one case. Conclusion: single-staged therapy of LFB and iNPWT hybridization is a technically handy and effective method for treatment of inguinal wound infection after arterial surgery.

Early definitive internal fixation for infected nonunion of the lower limb

Background The management of an infected nonunion of long bones is difficult and challenging. A staged procedure comprising radical debridement followed by definitive internal fixation was favored. However, no standard treatment has been established to determine the appropriate waiting period between initial debridement and definitive internal fixation. We propose a management method that incorporates early definitive internal fixation in infected nonunion of the lower limb. Methods Thirty-four patients (28 men and 6 women; mean age 46.09 years; range 25–74 years) with infected nonunion of the tibia or femur were included. Initial infected bone resection and radical debridement were performed in each patient in accordance with the preoperative plans. Definitive surgery was performed 2–3 weeks after the resection (4 weeks after flap surgery was required), and a third surgery was performed to fill the bone defect through bone grafting or transport (three-stage surgery). In cases of unplanned additional surgery, the reason for the requirement was analyzed, and radiological and functional results were investigated in accordance with the Association for the Study and Application of the Method of Ilizarov criteria. Results Bone union was achieved in all patients, and treatment was conducted as planned preoperatively in 28 patients (28/34, 82.35%). The mean interval between primary debridement and secondary definitive fixation was 2.76 weeks (range 2–4 weeks). Six unplanned additional surgeries were performed, and the infection relapsed in two cases. The radiological and functional outcomes were good or better in 32 and 31 patients, respectively. Conclusions Early definitive surgery can be performed to treat infected nonunion by thorough planning and implementation of radical resection, active response to infection, restoration of defective bones, and soft tissue healing through a systemic approach.

Management of a mutilated hand: the current trends

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Early Definitive Internal Fixation for Infected Nonunion of The Lower Limb

Background Management of an infected nonunion of the long bones is quite difficult and challenging. A staged procedure comprising of radical debridement followed by definitive internal fixation is favored. However, no standard treatment has been established for determining the appropriate waiting period between the initial debridement and the definitive internal fixation. We proposed a management incorporating early definitive internal fixation for infected nonunion of the lower limb. Methods Thirty-four patients (28 men and six women; mean age, 46.1 years; range, 25–74 years) with infected nonunion of the tibia or femur were included. Initial infected bone resection and radical debridement were performed for each patient in accordance with the preoperative plans. Definitive surgery was performed 2–3 weeks after the resection (4 weeks after flap surgery was required), and the third surgery was performed to fill the bone defect through bone grafting or transport (three-stage surgery). In cases of unplanned additional surgery, the reason for the requirement was analyzed, and radiological and functional results were investigated in accordance with the Association for the Study and Application of the Method of Ilizarov criteria. Results Bone union was achieved in 100% of the patients, and treatment was conducted as planned preoperatively in 28 patients (28/34, 82.4%). The mean interval between the primary debridement and the secondary definitive fixation was 2.76 weeks (range, 2–4 weeks). Six unplanned additional surgeries were performed, and the infection relapsed in two cases. The radiological and functional outcomes were good or better in 32 and 31 cases, respectively. Conclusions Early definitive surgery can be performed to treat infected nonunion by thorough planning and implementation of radical resection, active response to infection, restoring defected bones, and soft tissue healing through a systemic approach.