Utilisation of bioactive glass S53P4 inside an induced membrane for severe bone defect with high risk of infection: a multi-center preliminary experience.

BACKGROUND: The induced membrane technique has been developed to address bone defect of critical size from various origins. Despite its exceptional efficacy, several cases underwent a failure, which is regularly associated with a septic problem. The best way to conduct in this situation remains debated. PURPOSE: To estimate use of bioactive glass S53P4 (BAG-53P4) in induced membrane technique failures or with an anticipated high risk of failure. MATERIAL AND METHOD: We conducted a retrospective analysis of patients from several medical centers in Europe where BAG-S53P4 has been used inside an induced membrane. The etiology of the defect, the bone fixation used, the delay the bioactive glass was placed, the reason why the bioactive glass was used and the results were reported. RESULTS: Eight cases were included (3 women and 5 men). Mean age was 43 years (16-82; Standard deviation 23). Mean height was 171 cm (162-184; SD 7), mean weight was 69 kg (60-85; SD 8) and Body Mass Index was 23,39 M/Kg2 (21,9-25,1; SD 1,22). Mean length of defect was 68 mm (40-100mm, SD 23). All patients received BAG-S53P4 granules (BonAlive Biomaterials Ltd, Turku, Finland) to fill the resultant cavity (3 as a stand-alone in the induced membrane and 5 mixed with autograft). Three patients were implanted with BAG-S53P4 during the second stage of a first induced membrane technique because of a high risk of infection (three open fractures); two patients were implanted with BAG-S53P4 during the second stage of a first induced membrane technique because of the great size of the defect (two infectious non-union); two patients were implanted with BAG-S53P4 as a third stage of induced membrane technique, i.e. inside a previously grafted membrane, because of a recurrence of the infection; and one patient was implanted with BAG-S53P4 during the second stage of a second induced membrane technique to avoid a new failure. At a follow-up of 16 months, all healed without any recurrence of the infection. DISCUSSION: Critical size bone defects caused by an open fracture or an active infection can usually be addressed by the induced membrane technique. However, some cases are at high risk of failure because of the occurrence or recurrence of an infection. In these cases, bioactive glass may help the surgeon to improve the rate of bone union. CONCLUSION: BAG-S53P4 may be considered as bone graft in an induced membrane technique, especially when there is a high probability of occurrence or recurrence of a bone infection.

Bioactive glass S53P4 vs. autologous bone graft for filling defects in patients with chronic osteomyelitis and infected non-unions - a single center experience.

Introduction: The goals of osteomyelitis therapy are successful control of infection and reconstruction of the bone. The gold standard for filling defects is the autologous bone graft. Bioactive glass S53P4 is an inorganic bone substitute. We compared the outcome of using bioactive glass (BAG) versus autologous bone graft (AB) in patients with infected non-union. Methods: Patients with chronic osteomyelitis and infected non-union who received either bioactive glass or autologous bone grafts between 2013 and 2017 were analyzed retrospectively. The primary endpoint was successful control of infection during follow-up. Secondary endpoints were bone healing, functional outcome, and occurrence of complications. Results: Eighty-three patients were analyzed (BAG n = 51 , AB n = 32 ). Twenty-one patients experienced reinfection (BAG n = 15 , 29 %; AB n = 6 , 19 %). Seventy-eight patients achieved full weight bearing (BAG n = 47 , 92 %; AB n = 31 , 97 %). Sixty-four patients had complete bone healing at the end of the follow-up period (BAG n = 39 , 77 %; AB n = 25 , 78 %). There were no significant differences between the groups with respect to the primary or secondary endpoints. Patients with multidrug-resistant pathogens had a significantly higher rate of incomplete bone healing ( p = 0 .033) and a 3-fold higher risk of complications in both groups. Conclusions: Bioactive glass appears to be a suitable bone substitute not only for successful control of infection and defect filling but also for bone healing in cases of infected non-union. In our study, bioactive glass was neither superior nor inferior to autologous bone graft with regard to the primary and secondary endpoints. Further studies with larger numbers of patients are required.

C-Nail versus plate osteosynthesis in displaced intra-articular calcaneal fractures-a comparative retrospective study.

BACKGROUND: Locking plate osteosynthesis via an L-shaped lateral approach is the gold standard in treating displaced intra-articular calcaneal fractures. High complication rates are known for this approach. The most frequent complications are wound edge necrosis and superficial wound infections. To reduce complication rates, a locking intramedullary nail (C-Nail) was developed that can be implanted minimally invasively via a sinus tarsi approach. We compared the postoperative complication rate and the outcome of plate osteosynthesis versus C-Nail in displaced intra-articular calcaneal fractures. METHODS: All patients with calcaneal fractures who received osteosynthesis with either plate or C-Nail between January 2016 and October 2019 in our institution were retrospectively analyzed. A subgroup analysis was performed with matched pairs (matching Sanders type, age, Böhler's angle postoperative in normal range, 33 pairs). Endpoints were postoperative complication rate, bone healing, full weight-bearing and functional outcome. Treatment groups were compared using Fisher's exact test for binary data, and Mann-Whitney U-test for continuous data. A p-value < 0.05 was considered statistically significant. RESULTS: One hundred and one calcaneal fractures were included (C-Nail n = 52, plate n = 49). Patients with C-Nail developed significantly less postoperative complications (p = 0.008), especially wound edge necrosis (p < 0.001). Screw malposition was found more often in the C-Nail group. The rates of achieving full weight-bearing as well as bone healing were comparable in both groups, but in each case significant faster in the C-nail subgroup. The results of the matched-pairs analysis were comparable. CONCLUSIONS: The postoperative complication rate was significantly lower in the C-Nail group. The C-Nail appears to be a successful alternative in the treatment of calcaneal fractures, even in Sanders IV fractures because of the minimal-invasive implantation as well as the high primary stability. Long-term analysis of this new implant including elaboration on functional outcome is planned. TRIAL REGISTRATION: Deutsches Register Klinischer Studien (DRKS) DRKS00020395 . Date of registration 3 January 2020.

External versus internal fixation for arthrodesis of chronic ankle joint infections - A comparative retrospective study.

BACKGROUND: Arthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard. We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint. METHODS: All patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing. RESULTS: Seventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p=0.019), achieved full weightbearing significantly more often (p=0.042) and faster and developed significantly fewer complications (p<0.001). Forty-three patients showed bone fusion without significant differences between the groups. CONCLUSIONS: Ankle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.

[Successful prehospital emergency thoracotomy after blunt thoracic trauma : Case report and lessons learned]. / Erfolgreiche präklinische Notfallthorakotomie nach stumpfem Thoraxtrauma : Fallbericht mit Darstellung gewonnener Erkenntnisse.

BACKGROUND: The European Resuscitation Council guidelines for resuscitation in patients with traumatic cardiac arrest recommend the immediate treatment of all reversible causes, if necessary even prior to continuous chest compression. In the case of cardiac tamponade immediate emergency thoracotomy should also be considered. OBJECTIVE: The authors report the case of a 23-year-old male patient with multiple injuries including blunt thoracic trauma, which caused a witnessed cardiac arrest. He successfully underwent prehospital emergency resuscitative thoracotomy. The lessons learned from this case on internal and external quality measures are discussed in detail. RESULTS: After 60 min of technical rescue, extensive trauma life support including intubation, chest decompression and bleeding control was carried out. The cardiovascular insufficiency progressively deteriorated and under the suspicion of a cardiac tamponade a prehospital emergency thoracotomy was carried out. After successful resuscitative thoracotomy and return of spontaneous circulation (ROSC) the patient was airlifted to the next level 1 trauma center for damage control surgery (DCS). The patient could be discharged 59 days after the accident and now 2 years later is living a normal life without neurological or cardiopulmonary limitations. Airway management, chest decompression including resuscitative thoracotomy, fluid resuscitation and blood products were the key components to ensure that the patient achieved ROSC. Advanced Trauma Life Support® as well as structural prerequisites made these measures and good results for the patient possible.

The Use of Bioactive Glass S53P4 as Bone Graft Substitute in the Treatment of Chronic Osteomyelitis and Infected Non-Unions - a Retrospective Study of 50 Patients.

BACKGROUND: Treatment of chronic osteomyelitis (COM) remains challenging and often results in large bone defects. Dead space management and proper defect filling are essential for successful treatment. Bioactive glass S53P4 (BAG-S53P4) is an anorganic bone graft substitute with antibacterial, osteoconductive, osteostimulative and angiogenic properties. The aim of our study was to analyse the outcome of patients with COM and infected non-unions, whose bone defects were filled with BAG-S53P4. MATERIAL AND METHODS: In this retrospective study (07/13 - 02/16), we analysed all patients with COM and infected non-unions, who obtained BAG-S53P4 after surgical debridement to fill their bone defects. Epidemiological data, pre-, peri- and postoperative characteristics were evaluated. The primary endpoint was the successful control of infection during the follow-up period. Secondary endpoints were the absence of BAG-S53P4-related complications, the time period to full weight bearing as well as to radiologically detectable incorporation of BAG. X-ray examinations were routinely performed 1 month, 3 - 4 months, 6 months and 12 months postoperatively. RESULTS: 50 patients were analysed. Staphylococcus aureus was the most common pathogen involved. On average, 11.1 ± 6.7 cm3 BAG-S53P4 were implanted. Mean follow-up was at 12.3 months. After 6 months, 26/37 (70.3%) and after 12 months, 35/42 (83.3%) of the filled bone defects were healed. X-ray examinations showed a thickened neo-cortex. 40 patients (80%) have achieved full weight bearing after a mean of 4 months. There were no complications at all in 76% of patients. Seven patients suffered reinfection. BAG-associated complications were not seen. CONCLUSIONS: The use of BAG-S53P4 in patients with COM and infected non-unions is promising. Adequate debridement and proper defect filling are necessary. BAG is well tolerated. X-ray examinations showed a thickened neo-cortex. The antibacterial effect is not mediated by antibiotics and is advantageous in times of evolving antibiotic resistance. High quality studies with a longer follow-up are required. TRIAL REGISTRATION: TRN DRKS00011679.

[Thigh abscess as first manifestation of a sigma carcinoma]. / Oberschenkelabszedierung als Erstmanifestation eines metastasierten Sigmakarzinoms.

MEDICAL HISTORY: An extensive thigh abscess was the reason for a hospital admission of a 66 year old woman. Apart from that there were no other known preexisting diseases. INVESTIGATIONS: The reason for the abscess was a perforated sigma carcinoma, which was incidentally found. Treatments and course: We treated the patient with a sigma resection and several debridements of the thigh. But for all that she died from septic shock. CONCLUSION: This case illustrates the importance of cancer screening programs and an accurate investigation of the medical history and clinical examination. This can be supported by a failure management, which does not sanction a failure but considers it as a chance for future improvement.

Reconstruction of septic diaphyseal bone defects with the induced membrane technique.

Septic segmental bone voids of the diaphysis are difficult to manage. The induced membrane technique by Masquelet has been successfully used to reconstruct segmental defects more than 20 cm. Our article describes a series of 13 cases with extensive posttraumatic bone loss of the metatarsal, tibial, femoral and radial bones after septic injuries followed by multiple surgical interventions. Antibiotic-impregnated polymethyl methacrylate (PMMA) cement spacers were implanted after successful eradication of bacterial infections of soft tissue and bones. After a mean of 9.8 weeks, body-induced membranes were established and the cements spacers removed. To fill up the bone void, cancellous bone autografts were implanted into the membranes. The follow-up examination after 24 months revealed bony union in all cases and favorable functional results. The induced membrane technique has shown to be effective in treating bone defects of upper and lower extremity bone defects.