Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group.

A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.

A natural history of untreated chronic osteomyelitis of the tibia over 20 years, with evolving squamous cell carcinoma: a case report.

Squamous cell carcinoma (SCC) is a rare but potentially life-threatening complication of chronic osteomyelitis. Whilst there have been over 100 cases of chronic osteomyelitis with malignant transformation reported in the literature between 1999 and 2020, this is the first case report to document transformation with 20 years of concordant imaging and clinical review.

Comment on Niemann et al. Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects. Diagnostics 2022, 12, 1207.

We read the recent study by Niemann et al. (2022) [...].

Mid- to long-term results of single-stage surgery for patients with chronic osteomyelitis using a bioabsorbable gentamicin-loaded ceramic carrier.

AIMS: Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. METHODS: A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). RESULTS: At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of nonunion before surgery (1/10 with nonunion (10%) vs 5/90 without nonunion (5.6%); p = 0.570). Organisms with intermediate or high-grade resistance to gentamicin were significantly more likely in polymicrobial infections (9/21; 42.8%) compared with monobacterial osteomyelitis (7/79 (8.9%); p < 0.001). However, recurrence was not significantly more frequent when a resistant organism was present (1/16 for resistant cases (6.25%) vs 5/84 in those with a microbiologically sensitive infection (5.95%); p = 0.958). CONCLUSION: We found that a single-stage protocol, including the use of a high-delivery local antibiotic ceramic carrier, was effective over a period of several years. The method can be used in a wide range of patients, including those with significant comorbidities and an infected nonunion.Cite this article: Bone Joint J 2022;104-B(9):1095-1100.

The Role of Negative-Pressure Wound Therapy in Patients with Fracture-Related Infection: A Systematic Review and Critical Appraisal.

INTRODUCTION: Fracture-related infection (FRI) is a severe musculoskeletal complication in orthopedic trauma surgery, causing challenges in bony and soft tissue management. Currently, negative-pressure wound therapy (NPWT) is often used as temporary coverage for traumatic and surgical wounds, also in cases of FRI. However, controversy exists about the impact of NPWT on the outcome in FRI, specifically on infection recurrence. Therefore, this systematic review qualitatively assesses the literature on the role of NPWT in the management of FRI. METHODS: A literature search of the PubMed, Embase, and Web of Science database was performed. Studies that reported on infection recurrence related to FRI management combined with NPWT were eligible for inclusion. Quality assessment was done using the PRISMA statement and the Newcastle-Ottawa Quality Assessment Scale. RESULTS: After screening and quality assessment of 775 unique identified records, eight articles could be included for qualitative synthesis. All eight studies reported on infection recurrence, which ranged from 2.8% to 34.9%. Six studies described wound healing time, varying from two to seven weeks. Four studies took repeated microbial swabs during subsequent vacuum dressing changes. One study reported newly detected pathogens in 23% of the included patients, and three studies did not find new pathogens. CONCLUSION: This review provides an assessment of current literature on the role of NPWT in the management of soft tissue defects in patients with FRI. Due to the lack of uniformity in included studies, conclusions should be drawn with caution. Currently, there is no clear scientific evidence to support the use of NPWT as definitive treatment in FRI. At this stage, we can only recommend early soft tissue coverage (within days) with a local or free flap. NPWT may be safe for a few days as temporarily soft tissue coverage until definitive soft tissue management could be performed. However, comparative studies between NPWT and early wound closure in FRI patients are needed.

Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection.

Chronic bone infections often present with complex bone and soft tissue loss. Management is difficult and commonly delivered in multiple stages over many months. This study investigated the feasibility and clinical outcomes of reconstruction in one stage. Fifty-seven consecutive patients with chronic osteomyelitis ( n = 27 ) or infected non-union ( n = 30 ) were treated with simultaneous debridement, Ilizarov method and free muscle flap transfer. 41 patients (71.9 %) had systemic co-morbidities (Cierny-Mader group Bs hosts). Infection was confirmed with strict criteria. 48 patients (84.2 %) had segmental defects. The primary outcome was eradication of infection at final follow-up. Secondary outcomes included bone union, flap survival and complications or re-operation related to the reconstruction. Infection was eradicated in 55 / 57 cases (96.5 %) at a mean follow-up of 36 months (range 12-146). No flap failures occurred during distraction but 6 required early anastomotic revision and 3 were not salvageable (flap failure rate 5.3 %). Bony union was achieved in 52 / 57 (91.2 %) with the initial surgery alone. After treatment of the five un-united docking sites, all cases achieved bony union at final follow-up. Simultaneous reconstruction with Ilizarov method and free tissue transfer is safe but requires careful planning and logistic considerations. The outcomes from this study are equivalent or better than those reported after staged surgery.

Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art.

Osteomyelitis (OM) of the lower limb represents a large unmet global healthcare burden. It often arises from a contiguous focus of infection and is a recognized complication of open fractures or their surgical treatment, arthroplasty, and diabetic foot ulcers. Historically, this debilitating condition is associated with high rates of recurrence and secondary amputation. However, excellent long-term outcomes are now achieved by adopting a multidisciplinary approach with meticulous surgical debridement, skeletal and soft tissue reconstruction, and tailored antimicrobial treatment. This review focuses on the modern evidence-based management of post-traumatic OM in the lower limb from a reconstructive plastic surgery perspective, highlighting the latest developments and areas of controversy.

Lymphaticovenular anastomosis improves quality of life and limb volume in patients with secondary lymphedema after breast cancer treatment.

Secondary lymphedema is a common side effect of breast cancer treatment, with significant impact on patients' physical and psychological well-being. Conservative therapies are the gold standard treatment, however surgical options are becoming more popular. Lymphaticovenular anastomosis (LVA) is a supermicrosurgical procedure that aims to restore lymphatic flow by anastomosing damaged lymphatics to subcutaneous venules. We aimed to assess the effects of LVA on patients' limb volume and quality of life. Pre- and postoperative limb volumes and LYMQOL scores were collected for patients undergoing LVA for lymphedema secondary to breast cancer. Thirty-seven patients underwent LVA. A significant reduction was seen in median excess limb volume postoperatively (13.3%-6.6%, P < 0.005), with volumetric improvement seen in 78% of patients. Thirteen patients were able to discontinue compression garment use. Eighty-six percent of patients reported improved quality of life postoperatively with median LYMQOL score increasing from 90 to 104 points (P < 0.005). LVA is a minimally invasive surgical option for patients with early stage lymphedema. It can lead to significant volumetric improvements and in select patients, freedom from compression therapy. LVA can also lead to significant improvements in quality of life, in particular patients' mood and perception of their appearance.

Lymphaticovenular anastomosis in the treatment of secondary lymphoedema of the legs after cancer treatment.

OBJECTIVE: As survival from cancer continues to improve, greater importance is placed on quality of life after surgery. Lymphoedema is a common and disabling complication of cancer treatment. Lymphaticovenular anastomosis (LVA) is a supermicrosurgical treatment option for lower limb lymphoedema. The aim of this study was to assess the effectiveness of LVA in reducing limb volume and its effect on quality of life of patients with secondary leg lymphoedema following treatment for cancer, including gynaecological cancers. METHODS: Limb volume and patient rated quality of life were collected prospectively pre-operatively and at every post-operative appointment in this case series. All patients presenting to the clinic with stable or progressive leg lymphoedema despite conservative therapy who were suitable candidates for LVA over a three-year period were included. RESULTS: Twenty-nine patients were treated with LVA, 19 for unilateral lymphoedema and 10 for bilateral. In unilateral cases median limb excess volume reduced from 27% to 16% post-operatively (p < 0.005) and in bilateral cases a median 8% reduction in absolute limb volume was achieved. Significant improvement in patient-reported quality of life was demonstrated, as measured by the LYMQOL: 23% improvement in unilateral and 14% improvement in bilateral patients (both p < 0.05). CONCLUSIONS: In selected patients with early stage lymphoedema secondary to cancer treatment, LVA offers a minimally invasive surgical option that can achieve significant volumetric and quality of life improvements.

Costs and renumeration of osteomyelitis treatment involving free flaps: implications of return to theatre.

Aim: This study aimed to define the costs of surgical management of chronic osteomyelitis where free tissue transfer was required in addition to debridement of bone, particularly the increased costs incurred by a return to theatre. We hypothesised that there would be a significantly greater cost when patients required re-exploration for vascular compromise. Method: We retrospectively analysed the costs of a consecutive series of sixty patient episodes treated at the Bone Infection Unit in Oxford from 2012 to 2015. Treatment involved excision of osteomyelitis with free tissue transfer for immediate soft tissue cover. We compared the costs of uncomplicated cases with those who returned to theatre and determined the profit / loss for the hospital from renumeration through the UK National Health Service Tariff Structure. Results: Hospital income according to UK HRG tariff was compared to the actual cost of treatment and these 60 cases were significantly underfunded overall (P < 0.005). In just 1 case, the cost to the hospital was completely covered by tariff. Six patients (10%) returned to theatre for urgent flap re-exploration with five flaps salvaged and one failed, requiring another free flap reconstruction (1.7%). These six patient episodes had a significantly higher mean cost compared to the uncomplicated cases. The average financial loss to the hospital for patients who did return to theatre was £19401 (range £8103 to £48380) and in those who did not was £9600 (range - £600 to £23717). The case requiring further free tissue transfer cost a total of £74158, £48380 more than the hospital was paid: the most extreme discrepancy. The overall loss for this group of 60 patients was £610 090. Conclusions: Surgery for chronic osteomyelitis is multidisciplinary, complex and therefore expensive with a significant risk of complications. However, this study demonstrates that the hospital currently makes a financial loss on almost all patients but especially if flap complications occur. This study has implications for the long term viability of specialist units treating this important disease.

Labial reconstruction with a cross-labial flap.

Overzealous resection of the labia minorum is a significant complication of labioplasty. Knowledge and understanding of reconstructive plastic surgical principles are required to manage such challenging complications. We report a case of iatrogenic labial asymmetry that was reconstructed with a cross-labial flap.

Facial acne and fine lines: transforming patient outcomes with plasma skin regeneration.

BACKGROUND: A novel device for skin rejuvenation has been developed and tested. The device converts a stream of nitrogen into a plasma of ionized gas, which ablates surface tissue in a controlled manner. METHODS: Eleven patients were followed up for 6 months. The results were assessed objectively using skin molds to measure skin irregularity, as well subjectively using patient- and doctor-assessed parameters. RESULTS: Plasma skin regeneration was shown to reduce fine line wrinkles by an average of 24% at 6 months (P = 0.005, Mann-Whitney rank sum test) and to improve acne scarring by 23% at 6 months (P = 0.001, Mann-Whitney rank sum test). CONCLUSIONS: The main benefit of this system was that the patients had minimal erythema lasting only 1-6 days and no pigmentary changes. This is therefore a device with proven efficacy and limited morbidity.