Single-stage versus two-stage bone flap reconstruction in chronic osteomyelitis: Multicenter outcomes comparison.

BACKGROUND: Chronic osteomyelitis is an invalidating disease, and its severity grows according to the infection's particular features. The Cierny-Maiden criteria classify it according to the anatomical aspects (I to IV) and also by physiological class (A host being in good immune condition and B hosts being locally (L) or systemically (S) compromised). The surgical approach to chronic osteomyelitis involves radical debridement and dead space reconstruction. Two-stage management with delayed reconstruction is the most common surgical management, while one-stage treatment with concomitant reconstruction is a more aggressive approach with less available literature. Which method gives the best results is unclear. The purpose of this study is to compare single and two-stage techniques. METHODS: The authors carried out a retrospective multicentric cohort study to compare two primary outcomes (bone union and infection healing) in one versus two-stage reconstructions with vascularized bone flaps in 23 cases of limb osteomyelitis (22 patients, 23 extremities). Thirteen subjects (56.5%) sustained a single-stage treatment consisting of a single surgery of radical debridement, concomitant soft tissue coverage, and bone reconstruction. Ten cases (43.5%) sustained a two-stage approach: radical debridement, simultaneous primary soft tissue closure, and antibiotic PMMA spacers implanted in 7 patients. RESULTS: No statistical differences were observed between one- and two-stage approaches in bone union rate and infection recurrence risk. Even though bone union seems to be higher and faster in the two-stage than in the one-stage group, and all infection relapses occurred in the one-stage group, data did not statistically confirm these differences. Two of the six cases (33.3%) of bone nonunion occurred in compromised hosts (representing only 17.4% of our sample). The B-hosts bone union rate was 50.0%, while it reached 78.9% in A-hosts, but the difference was not statistically significant (p = .5392). Infection recurrence was higher in B-hosts than in A-hosts (p = .0086) and in Pseudomonas aeruginosa sustained infections (p = .0208), but in the latter case, the treatment strategy did not influence the outcome (p = .4000). CONCLUSIONS: Bone union and infection healing rates are comparable between one and two-stage approaches. Pseudomonas aeruginosa infections have a higher risk of infection relapse, with similar effectiveness of one- and two-stage strategies. B-hosts have a higher infection recurrence rate without comparable data between the two approaches. Further studies with a larger sample size are required to confirm our results and define B-hosts' best strategy. LEVEL OF EVIDENCE: Level III of evidence, retrospective cohort study investigating the results of treatments.

Direct anterior approach in total hip arthroplasty: influence of stem length on clinical and radiological outcomes at medium-term follow-up.

PURPOSE: To evaluate the influence of short versus long stems implanted through a Direct Anterior Approach (DAA) on clinical and radiological outcomes in THA at medium-term follow-up (average follow-up of 44.8 months). METHODS: 167 consecutive total hip arthroplasties treating patients affected by primary hip osteoarthritis were retrospectively evaluated. A standard-length stem (H-MAXs) was used in 70 patients, while a short metaphyseal-fitting femoral stem (MINIMA) was used in 97 patients. The Harris Hip Score (HHS) and Forgotten Joint Score-12 (FJS) were used as outcomes measurements. Post-operatively, Engh's score and Brooker classification were analyzed at 6 months, 1 year and every 2 years until the final FU. The correct size of the implant was evaluated determining the canal fill index (CFI), and all undersized stems were classified according to Magra classification. RESULTS: The average HHS was 83 ± 13.4 in the standard stems group and 87 ± 14.1 for short stems group (p = 0.148). The average FJS was 87.9 ± 15.2 for patients in the standard stems group and 84.5 ± 17.7 with no significant differences (p = 0.327). None of the stems showed radiographic signs of instability (standard stems mean Engh's score: 19.25 versus short stems mean Engh's score: 19.50-p = 0.41). According to Brooker classification, no significant difference in severity was found using different stems (p = 0.715). A high rate of undersized stems was found (standard stems 24%-short stems 25%) but without statistical difference between groups (p = 0.078), while a different trend in malposition following the recent classification proposed by Magra et al. was observed evaluating all undersized stems (p = 0.0387). CONCLUSIONS: Both groups achieved good and comparable patient-reported outcome measurements (PROMs) and radiographic stability with fixation observed by bone ingrowth. A high rate of undersized stems was found with a correlation between femoral stem length and specific pattern of malposition. Malalignment in Varus was frequent in shorter stems in contact proximally with medial calcar and distally with lateral cortex, while a uniform undersizing was observed for longer ones with a continuous margin around the stem. However, the stems never presented progressive radiolucent lines over the whole surface of the stem.

Intravenous treatment with biphosphates in Complex Regional Pain Syndrome.

BACKGROUND: Complex Regional Pain Syndrome (CRPS) is a pathological persistence of spontaneous or evoked disproportionate pain. Several drugs are employed, but only bisphosphonates seem to have good outcomes. The purpose of our research is to analyze the characteristics of the cases victims of CRPS and study the beneficial effect of the intravenous nerindronic acid sodium salt (Nerixia®), in an attempt to improve the results in this disabling disease. Materials and methods: We retrospectively examined 30 cases of CRPS that had undergone intravenous nerindronic acid sodium salt therapy in our center. The patients were contacted after 12 months from the start of therapy and their clinical situation was assessed with Quick DASH Score. Results: The average age of our group was 59,76 years (span, 42-78), and female subjects were 84% (p-value <0.05). 72% of all cases were complications of wrist fractures.). The Quick DASH Score (19 points are the best result, 95 the worst outcome) average was 41,1 points. The values of Quick DASH Score differed significantly (p-value <0.001) according to the age of the patient. In addition, the DASH Score values were related to the sex of the patient (p-value <0.001). Male subjects have obtained a better score. After 12 months of intravenous therapy, 52% of cases reports that they still have joint stiffness. The DASH values differed significantly depending on the onset of intravenous treatment (p-value <0.001). Conclusion: Our study showed that the CRPS affects a population between 42 and 78 years, especially women. Treatment with intravenous bisphosphonates seems to lead to an improvement in CRPS symptoms, in particular administration between 3 and 6 months after the onset of the disease. In particular, women over 61 years of age seem to have a lower improvement in symptomatology after treatment. 52% of cases report that they still have joint stiffness.

Treatment of chronic Osteomyelitis with vascularized bone flaps in one-stage-procedure.

BACKGROUND: Chronic osteomyelitis is a long-standing infection of the bone. Treatment is often combined, using antibiotics and surgery (with radical debridement and secondary or concomitant reconstruction). One-stage management is an alternative approach, with few reported cases in literature. PATIENTS/MATERIAL AND METHODS: We carried out an observational retrospective multicenter study to evaluate the results of one-stage reconstructions with vascularized bone flaps. We assessed bone and infection healing in 14 cases, with a mean follow-up of 63.6 months. RESULTS: Bone union was obtained in 10 cases (71.4 %) in a mean period of 7.9 months. Nonunion occurred in 4 cases (28.6 %), 2 of them with infection persistence. Bone nonunion risk increases in polymicrobial infections (p = 0.0269) and in compromised hosts (p = 0.0110). Infection healing was achieved in 11 cases (78.6 %). Fistula recurred in 3 cases of forearm osteomyelitis (21.4 %) in 10 months on average. Infection recurrence is associated with polymicrobial infections (p = 0.0378) and is higher in internal fixation and compromised hosts with no statistically significant relation. CONCLUSIONS: One-stage surgical treatment seems to be an effective approach in selected patients, in particular when an important impairment of local soft tissue and bone exposure are present, and immediate bone coverage with vascularized soft tissue is needed. Most complications occurred in compromised hosts and in patients with polymicrobial cultures. Further research, with comparison between one and two-stage procedures, is needed in order to strengthen the level of evidence.