Osteomyelitis is an infectious process in bone that occasionally leads to bone destruction. Traditionally, the surgical treatment procedure is performed in combination with systemic and local ...antibiotics as a two-stage procedure that uses autograft or allograft bone for filling of the cavitary defect. Bioactive glass (BAG-S53P4) is a bone substitute with proven antibacterial and bone bonding properties.One hundred and sixteen patients who had verified chronic osteomyelitis was treated using BAG-S53P4 as part of the treatment. Most of the patients had previously undergone numerous procedures, sometimes for decades. A register of patient data obtained from 11 centers from Finland, Italy, the Netherlands, Germany, Azerbaijan and Poland was set-up and continuously maintained at Helsinki University Central Hospital.The location of the osteomyelitis was mainly in the tibia followed by the femur and then the calcaneus. The median age of the patients was 48 years (15-87). The patients were either treated according to a one-stage procedure without local antibiotics (85 %) or by a two-stage procedure using antibiotic beads in the first procedure (15 %). The minimum follow-up was 1 year (12-95 months, median 31).The cure rate was 104/116, the total success rate 90 % and most of the patients showed a rapid recovery.The study shows that (BAG-S53P4) can be used in a one-stage procedure in treatment of osteomyelitis with excellent results.
Osteosynthesis is a surgical technique for the treatment of skeletal fractures through the implant of mechanical devices, such as plates and screws, in order to stabilize and fix the injured skeletal ...segment. It is preferred to the conservative treatment when the fracture requires immediate surgical correction or when, blocking the joints, degenerative changes could occur. Bone screws have different shapes and sizes depending on the intended use. In this study, six types of cortical bone screws were tested to determine the torque transmitted to the bone during the insertion. One Ti6Al4V tapered (Ø 6 mm) and five AISI 316L stainless steel – two straight (Ø 4 and 6 mm) and three tapered (Ø 4, 5, and 6 mm) – screws were used during the tests. Screws have been screwed into Sawbones (Sawbones® Pacific Research Laboratories, Inc., Vashon, USA) solid foam-type cylinders (external diameter 30 mm and thickness 3.5 mm) simulating the cortical bone diaphysis. Each of the 26 screws tested was inserted in a Sawbone cylinder five times, in five previously drawn equally spaced points, without any pilot holes. The experiment design was based on the ASTM standard for medical bone screws; two experi- enced orthopedic surgeons performed the insertions and removals of the screws using a hand-drill at 1 rev/s, aided by a metronome, and the torque was measured with a torsiometer throughout the tests. The mean and maximum torque resulted to be higher for larger diameter screws. Considering the same diameter, tapered screws showed a higher torque required for the extraction, which indicates stronger retention. However, in some cases, the Sawbones cylinder was fractured during the insertion of screws with a 6 mm diameter. Therefore, the use of medium-size tapered screws might be the most advisable compromise.
Background: Femoral shaft fractures, typical in younger people, are often associated with polytrauma followed by traumatic shock. In these situations, despite intramedullary nailing being the ...treatment of choice, external fixation could be used as the definitive treatment. The aim of this study is to report evidence regarding definitive treatment of femoral shaft fractures with monoaxial external fixation.
Methods: Between January 2006 and December 2015, 83 patients with 87 fractures were treated at the Department of Orthopaedics and Traumatology CTO of Turin, with a monoaxial external fixation device. Mean age at surgery, type of fracture, mean follow-up, time and modalities of treatment, non-weight bearing period, average healing, external fixation removal time, and complications were reported.
Results: The average patient age was 31.43±15.19 years. In 37 cases (42.53%) the right femur was involved. 73 (83.91%) fractures were closed, and 14 (16.09%) were open. The average follow-up time was 61.07±21.86 weeks. In 68 (78.16%) fractures the fixation was carried out in the first 24 hours, using a monoaxial external fixator. In the remaining 19 cases, the average delay was 6.80±4.54 days. Mean non-weight bearing time was 25.82±27.66 days (ranging from 0 to 120). The 87 fractures united at an average of 23.60±11.37 weeks (ranging from 13 to 102). The external fixator was removed after an average of 33.99±14.33 weeks (ranging from 20 to 120). Reported complications included 9.19% of delayed union, 1.15% of septic non-union, 5.75% of malunion, and 8.05% cases of loss of reduction.
Conclusions: External fixation of femoral shaft fractures in polytrauma is an ideal method for definitive fracture stabilization, with minimal additional operative trauma and an acceptable complication rate.
The Ilizarov external fixation technique has been widely used for the treatment of long-bone infected non-unions. After surgical infected bone resection, to allow filling of the remaining bone gap, ...biomaterials with antibacterial properties could be used. The aim of this study was to report outcomes of infected tibial non-unions treated using the Ilizarov technique and antibacterial bioactive glass.
Between April 2009 and December 2014, 26 patients with infected tibial non-unions were treated with the Ilizarov technique and possible use of the bioactive glass, S53P4. The Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, a clinical and radiographic evaluating tool, was used for assessing the sample.
The average age at the start of treatment was 51 years. The mean follow-up time was 113 weeks. According to the ASAMI Functional Scoring System, 10 excellent (38.5%) cases and 12 good (46.1%) values were recorded. According to the ASAMI Radiological System, they were excellent in 16 (61.5%) cases and good in nine (34.6%).
Treatment of infected tibial non-unions using the Ilizarov technique was effective in bone segment regeneration. To fill the remaining bone gap, additional bioactive glass S53P4 could be used, allowing a decrease in re-interventions and minimizing complications.
Femoral shaft fractures result from high-energy trauma. Despite intramedullary nailing (IMN) representing the gold standard option of treatment, external fixation (EF) can be used temporarily for ...damage control or definitively. The purpose of this study is to compare two different options, anterograde IMN and monoaxial EF, for the treatment of femoral shaft fractures.
Between January 2005 and December 2014, patients with femoral shaft fractures operated on in two centers were retrospectively evaluated and divided into two groups: the IMN group (
= 74), and the EF group (
= 73). For each group, sex; laterality; age; and AO classification type mean follow-up, mean union time, and complications were reported.
Both groups were found to have no statistical differences (
> 0.05) in sex, laterality, age, and AO classification types. In the IMN group the average surgery duration was 79.7 minutes (range 45-130). The average time for bone union was 26.9 weeks. Major complications occurred in 4 (5.4%) patients. In the EF group the average follow-up duration was 59.8 months (range 28-160). The average time for bone union was 24.0 weeks. Major complications occurred in 16 (21.9%) patients.
IMN is the gold standard for definitive treatment of femoral shaft fractures. In patients with severe associated injuries, EF should be a good alternative.
Purpose
To assess the technical feasibility of contrast-enhanced ultrasound (CEUS) in the monitoring of non-infected long bone nonunion healing.
Methods
Twenty-five patients (16 males; mean age: 40.4 ...± 11.7) with long bone nonunion were treated using surgery and mesenchymal stem cells and platelet-rich plasma. They performed CEUS up to 15 days before, 7 days, 4 and 8 weeks after treatment. To categorize the angiogenesis around the fracture site, the microvascular blood flow from CEUS was classified into four categories, depending on the portion of the investigated area that was involved in the neovascularization process: grade 0 = 0%; grade 1 = 0–30%; grade 2 = 30–70%; grade 3 = 70–100%. Nonparametric Friedman and Wilcoxon statistics were used.
Results
Before treatment, neovascularization was graded as 0 in 15/25 patients, as 1 in 10/25. Vascularity significantly increased over time (
P
< 0.001), namely: 1 (25th–75th percentile = 1–2) at 7 days; 2 (1–2) at 4 weeks; 3 (0–2) at 8 weeks. All patients but one showed early progressive increase in neovascularization well identified with CEUS at the fracture site.
Conclusion
CEUS is a feasible method to monitor healing in patients with long bone nonunion.
OBJECTIVES:To evaluate the results obtained using unilateral external fixation as a definitive treatment for humeral shaft fractures and to identify possible predictors of radiographic and functional ...outcomes.
DESIGN:Retrospective study.
SETTING:One large metropolitan hospital.
PATIENTS:A consecutive cohort of 107 patients who underwent external fixation for 109 humeral shaft fractures.
MAIN OUTCOME MEASURES:Union rate, time to fracture healing, and functional assessment with disabilities of the arm, shoulder, and hand questionnaire, Constant score, Mayo Elbow Performance Index, and return to prefracture sports activity at a minimum of 2 years after surgery. Comorbidities were evaluated using the Cumulative Illness Rating Scale. Multiple linear regression analysis was used to determine whether any explanatory variables were significantly associated with the outcomes.
RESULTS:The union rate in 109 humeral shaft fractures was 97.2% (106/109) at a mean of 99.2 days. Two patients (1.8%) had delayed union, and 1 patient (0.9%) did not achieve union. At the latest follow-up, the mean Constant score, Mayo Elbow Performance Index, and disabilities of the arm, shoulder and hand questionnaire score was 85.6, 97.4, and 7.4 points, respectively. All patients engaged in sports activities before fracture resumed a sport activity. At the multiple linear regression analysis, obesity was directly related to a delayed healing of fracture (P = 0.010) and comorbidity was the most important determinant of the functional outcomes at follow-up (P < 0.001).
CONCLUSIONS:These data support the use of unilateral external fixation as an effective therapeutic option in patients with humeral shaft fracture. Comorbidity as assessed by Cumulative Illness Rating Scale score is the most important determinant of functional outcomes.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The management of acute wounds may be affected by malpractices leading to poor outcome, prolonged hospital stay and inappropriate use of antibiotic therapy.
Acute wound infections are represented by ...surgical site and post-traumatic infections. The aim of this expert opinion is to identify a list of inadvisable actions and to provide a guide for an optimal management of acute wound infections. A literature search using Pubmed/MEDLINE database was performed. Articles pertaining to areas covered published until December 2019 were selected. We identified the most common malpractices in this setting and, using the Choosing Wisely methodology, we proposed a list of "Don'ts" for an easy use in clinical practice.
Malpractices may occur from the surgical prophylaxis to the discharge of patient. A prolonged surgical prophylaxis, the underestimation of signs and symptoms, the omission of source control, the inappropriate collection of wound swab, the improper use of clinical microbiology and pharmacology, the lack of hygiene measures and the delay of discharge are all factors that may lead to unfavorable outcome. A multidisciplinary approach is needed to optimally manage these patients. The "Don'ts" refer to all professional figures involved in the management of patients with acute wound infections.
Purpose
Bone transport is one of the most frequently used techniques for critical-sized bone defects due to trauma or infection. To fill the defect area and avoid the collapse of soft tissues during ...transport, some authors have described the use of polymethylmethacrylate or absorbable antibiotic carriers in the form of cylindrical blocks.
Methods
In this article, we present our experience in the treatment of post-traumatic osteomyelitis of the lower and upper limbs, using a bone transport technique with antibiotic-loaded calcium sulfate in the form of beads. Results
With the progressive absorption of calcium sulfate, we observed the formation of a bone-like tissue envelope at the periphery of the defect area. Histological analysis and direct visualization during open revision surgery of the docking site in all patients confirmed the presence of newly formed bone tissue with a high presence of osteoblasts and few osteoclasts; no areas of necrosis or signs of infection were observed. This bone envelope maintained the mechanical protective function of the transport path and docking site, and also provided a biological stimulus to avoid the development of necrotic areas and optimize the consolidation phase. Conclusion
Bone transport with calcium sulfate beads improves biological and mechanical support and reduces the number of surgeries required.
Background:
External fixation is an osteosynthesis technique particularly useful in trauma surgery and Damage Control Orthopedics (DCO). However, complications, such as pin loosening and pin tract ...infections, are fairly common. For reducing thermal damage and infection rates, monocortical pins have been proposed as an alternative to the most used bicortical pins. However, there is a lack of studies regarding their mechanical properties.
Objective:
The aim of the study is to assess the static and dynamic stability of a unilateral external fixator experimentally when applied through monocortical pins for the reduction of femur and tibia fractures.
Methods:
A modular unilateral external fixator was used and a total number of 6 pins were used per test. The static tests were performed in displacement control by applying a vertical displacement to the upper fixture at 1 mm/min until a tension load of 380 N was reached. The dynamic tests were performed by applying a sinusoidal displacement. During each test, forces and crosshead displacements were acquired. Two different stiffness indexes were assessed.
Results:
By comparing the two anatomic regions, it was found that the fixator behaves stiffer when mounted on the femur, regardless of the pins used, while stiffnesses comparable to the femur ones are reached by the tibia when 4 mm diameter pins are used. Static analysis revealed excellent fixator stability when implanted with 4 mm diameter monocortical pins on both anatomic regions. On the contrary, two tibia and one femur samples showed failures at the bone-pin interface when 3 mm diameter pins were used.
Conclusion:
Dynamic analysis showed no substantial difference between the tested configurations and confirmed the fixator's ability to sustain cyclic loading without further damage to the sample.
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