Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital.

BACKGROUND: Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team. METHODS: The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up. RESULTS: The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months. CONCLUSION: Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Risk Factors for Positive Cultures in Presumed Aseptic Revision Spine Surgery.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To report culturing patterns and results in the setting of presumed aseptic revision spinal surgery. SUMMARY OF BACKGROUND DATA: The indications for obtaining cultures in revision spinal surgery remain unclear in the absence of a definitive diagnosis of infection. Culture results and risk factors for having positive cultures in this setting have not been previously studied. METHODS: We retrospectively reviewed 595 consecutive revision spine surgeries performed by four senior spine surgeons between 2008 and 2013. Preoperative workup revealed the diagnosis of infection in 17 cases which were excluded from review. The remaining 578 presumed aseptic cases were included. Univariate and multivariate analyses were performed to identify variables associated with obtaining cultures and risk factors for positive cultures. RESULTS: Cultures were obtained in 112 (19.4%) cases and were positive in 40.2%. Pseudarthrosis was the most common revision diagnosis when cultures were obtained (49.1%) and Propionibacterium acnes was the most common organism isolated from positive cultures (48.8%). Regarding culture results, multivariate analysis demonstrated that male sex (odds ratio [OR] = 3.4) and pseudarthrosis (OR = 4.1) were significantly associated with having positive cultures while fusion procedures (OR = 0.3) were negatively correlated, with area under the curve (AUC) 0.71. CONCLUSION: Unexpected positive cultures occurred commonly and P. acnes was the predominant isolated organism. Male sex, pseudarthrosis, and non-fusion cases predicted positive cultures. Considering these results, we recommend cultures be obtained in revision cases for pseudarthrosis, even in the setting of negative infectious work-up preoperatively. LEVEL OF EVIDENCE: 4.

Case of femoral pseudarthrosis due to Scedosporium apiospermum in an immunocompetent patient with successful conservative treatment and review of literature.

Scedosporium apiospermum is a ubiquitous filamentous fungus, commonly found in soil, sewage and polluted waters. It is rarely pathogenic but can cause a broad spectrum of clinical diseases, which can be localised or disseminate to distant organs. The disseminated form of the disease is mostly seen among immunocompromised patients. However, some rare cases of disseminated disease have been reported in immunocompetent individuals. Treatment of these infections is challenging because of their natural resistance to many antifungal agents. Here, we report the case of a 57-year-old immunocompetent patient diagnosed with femoral pseudarthrosis due to S. apiospermum, despite having no obvious clinical sign of infection. Previously, the patient had undergone four iterative femoral surgeries following a road traffic accident which occurred 20 years before. During its last surgery for pseudarthrosis, no clinical or biological signs of infection were present. Per operative samples tested positive for S. apiospermum. The patient was successfully treated with oral voriconazole during 6 months with an excellent tolerance. We also provide a review of literature on bone and joint infections due to Scedosporium spp. (S. apiospermum, Scedosporium boydii and Scedosporium aurantiacum), discussing the evolution of their management and outcome which seems to improve since the use of voriconazole.

Microbiologic profile of infections in presumed aseptic revision spine surgery.

PURPOSE: Intra-operative cultures may be obtained in revision spine surgery despite the absence of pre-operative clinical markers of infection. The microbiologic profile of culture positive cases in which there is no clear evidence of infection preoperatively has not been described. The aim of this investigation is to report on the microbiologic profile of unexpected culture positive revision spine surgery cases. METHODS: We retrospectively reviewed 595 consecutive revision spine surgeries performed between 2008 and 2013. Five hundred and seventy-eight revision surgeries were performed for diagnoses other than infection and were included in the study. RESULTS: Operative cultures were obtained in 112 cases (19.4 %). Cultures were positive in 45 cases. Pseudarthrosis was not only the most common diagnosis overall (49.1 %) in which intra-operative cultures were obtained, it was also the most common revision surgical diagnosis where cultures were positive (55.6 %). Propionibacterium acnes was cultured in 54.2 % of cases with the primary diagnosis of pseudarthrosis, but only in 40.9 % of cases with other diagnoses (P = 0.554). Overall, staphylococcal species were found most commonly (57.8 % of cases), but P. acnes was at least one of the isolates in 48.9 % of cases and was three times more common than any other organism. CONCLUSIONS: Nearly one in five patients with the diagnosis of pseudarthrosis were culture positive. More specifically, pseudarthrosis was the most common culture positive diagnosis and P. acnes species predominated in this patient population. Propionibacterium acnes was overwhelmingly the most common single organism cultured in revision spine surgery. Given this, we recommend all cultures be held for P. acnes, particularly in the setting of pseudarthrosis.

Enrichment of bacteria samples by centrifugation improves the diagnosis of orthopaedics-related infections via real-time PCR amplification of the bacterial methicillin-resistance gene.

BACKGROUND: To effectively treat orthopaedic infections by methicillin-resistant strains, an early diagnosis is necessary. Bacterial cultures and real-time polymerase chain reaction (PCR) have been used to define methicillin-resistant staphylococci. However, even when patients display clinical signs of infections, bacterial culture and real-time PCR often cannot confirm infection. The aim of this study was to prospectively compare the utility of real-time PCR for the mecA gene detection following centrifugation of human samples with suspected orthopaedic infections. RESULTS: In addition to the conventional real-time PCR method, we performed real-time PCR following centrifugation of the sample at 4,830×g for 10 min in a modified real-time PCR (M-PCR) method. We suspended cultured methicillin-resistant Staphylococcus aureus and generated standard dilution series for in vitro experiments. The in vitro detection sensitivity of the M-PCR method was approximately 5.06 times higher than that of the conventional real-time PCR method. We performed bacterial culture, pathological examination, real-time PCR, and M-PCR to examine the infectious fluids and tissues obtained from 36 surgical patients at our hospital. Of these, 20 patients who had undergone primary total hip arthroplasty were enrolled as negative controls. In addition, 15 patients were examined who were clinically confirmed to have an infection, including periprosthetic joint infection (eight patients), pyogenic spondylitis (two patients), infectious pseudoarthrosis (two patients), and after spine surgery (three patients). In one sample from a patient who developed infectious pseudoarthrosis and two samples from surgical site infections after spine surgery, the mecA gene was detected only by the M-PCR method. In one patient with infectious pseudoarthrosis, one patient with infection after arthroplasty, and two patients with purulent spondylitis, the detection sensitivity of the M-PCR method was increased compared with PCR (clinical sample average: 411.6 times). CONCLUSIONS: These findings suggest that the M-PCR method is useful to detect methicillin-resistant strains infections. In addition, the centrifugation process only takes 10 min longer than conventional real-time PCR methods. We believe that the M-PCR method could be clinically useful to detect orthopaedic infections caused by methicillin-resistant strains.

Papineau debridement, Ilizarov bone transport, and negative-pressure wound closure for septic bone defects of the tibia.

PURPOSE: Ilizarov pioneered bone transport using a circular external fixator. Papineau described a staged technique for the treatment for infected pseudarthrosis of the long bones. This article presents a single-stage Papineau technique and Ilizarov bone transport, and postoperative negative-pressure wound dressing changes for septic bone defects of the tibia. MATERIALS AND METHODS: We studied the files of seven patients (mean age, 32 years) with septic bone defects of the tibia treated with a Papineau technique and Ilizarov bone transport in a single stage, followed by postoperative negative-pressure wound dressing changes. All patients had septic pseudarthrosis and skin necrosis of the tibia. The technique included a single-stage extensive surgical debridement of necrotic bone, open bone grafting with cancellous bone autograft and bone transport, and postoperative negative-pressure wound dressing changes for wound closure. The mean time from the initial injury was 6 months (range, 4-8 months). The mean follow-up was 14 months (range, 10-17 months). RESULTS: All patients experienced successful wound healing at a mean of 29 days. Six patients experienced successful bone regeneration and union at the docking side at a mean of 6 months. One patient experienced delayed union at the docking site, which was treated with autologous cancellous bone grafting. Two patients experienced pin track infection, which was successfully treated with antibiotics and pin site dressing changes. All patients were able to return to their work and previous levels of activity, except one patient who had a stiff ankle joint and had to change his job. No patient experienced recurrence of infection, or fracture of the regenerated or transported bone segment until the period of this study. CONCLUSION: The combined Papineau and Ilizarov bone transport technique with negative-pressure wound closure provides for successful eradication of the infection, reconstruction of the bone defect, and soft-tissue closure. A single-stage surgical treatment is feasible, without any complications.

[Infected pseudoarthrosis of the tibia, a pediatric case. Case report and literature review]. / Seudoartrosis infectada en tibia, un caso infantil. Caso clínico y revisión de la literatura.

Chronic posttraumatic osteomyelitis and infected pseudoarthrosis of the tibia are complex problems associated with considerable morbidity which may compromise the viability of the involved limb. The most frequent age of presentation is 2 to 6 years, with predominance in males at a 2:1 ratio. We present the case of a male 4 year-old patient with diagnosis of infected pseudoarthrosis. During the physical exam a fistula was detected in the anterior aspect of the right leg, with discharge of purulent material, and inability for weight bearing and gait. X-rays, culture of the exudate and biopsy were performed. Treatment consisted of antimicrobial therapy, surgical debridement's, and application of an autologous bone graft. The infection was controlled, the tibia healed, and function was restored.

Glycopeptide bone penetration in patients with septic pseudoarthrosis of the tibia.

BACKGROUND AND OBJECTIVE: In the treatment of bone infections, a major determinant of the clinical response is the active drug concentration at the infected site. Because of the high prevalence of meticillin (methicillin)-resistant staphylococci and enterococci, glycopeptides are widely used for the treatment of bone and joint infections, but data on their penetration into human bone are lacking. The aim of our study was to measure vancomycin and teicoplanin concentrations in infected human bone under steady-state conditions and verify their relationship with inflammatory markers, patient demographic characteristics and pharmacodynamic microbiological markers. METHODS AND PATIENTS: Twenty-seven adult orthopaedic patients undergoing surgical debridement for septic pseudoarthrosis of the tibia and receiving either intravenous vancomycin (Vancocina) 1 g twice daily) or teicoplanin (Targosid) 10 mg/kg/day) were studied from January 2004 to January 2008. Plasma and bone specimens were simultaneously collected during surgery for pharmacokinetic and microbiological assays at a variable interval after antimicrobial administration. Bone samples were dissected into cortical and cancellous bone, cleaned of soft tissues, crushed and eluted into phosphate buffer. Necrotic samples and sequestra were not analysed.Plasma and bone antimicrobial concentrations were measured by a validated method of high-performance liquid chromatography with UV detection, and bone/plasma concentration ratios were calculated. Cortical and cancellous bone area under the concentration-time curve (AUC) over 24 hours (AUC(24)) values were measured by the linear-log trapezoidal rule, using WinNonlin) software, and were compared with the minimum inhibitory concentrations (MICs) of the infecting agents. RESULTS: For vancomycin, the mean +/- SD concentrations were 2.66 +/- 1.2 mg/L in cortical bone and 11.53 +/- 7.8 mg/L in cancellous bone (corresponding to 20.67% and 89.39% of intraoperative plasma concentrations), and the mean +/- SD tissue AUC(24) values were 55.15 +/- 25.26 h . mg/L for cortical bone and 299.16 +/- 299.54 h . mg/L for cancellous bone. For teicoplanin, the mean +/- SD concentrations were 2.01 +/- 1.7 and 7.51 +/- 7.0 mg/L in cortical and cancellous bone, respectively (12.35% and 48.6% of intraoperative plasma concentrations), and the mean +/- SD teicoplanin tissue AUC(24) values were 34.08 +/- 23.6 h . mg/L and 155.17 +/- 132.8 h . mg/L for cortical bone and cancellous bone, respectively. The mean vancomycin AUC(24)/MIC ratios were 215.02 for plasma, 47.14 for cortical bone and 268.95 for cancellous bone. The mean teicoplanin AUC(24)/MIC ratios were 336.48, 36.27 and 197.21 for plasma, cortical bone and cancellous bone, respectively. CONCLUSIONS: Bone penetration of both glycopeptides ranged from poor (<15%) to satisfactory (15-30%) in the cortical compartment, while it was far higher into the highly vascularized cancellous tissue. Vancomycin bone penetration was slightly higher than with teicoplanin, but the difference was not statistically significant. Higher bone concentrations were observed with higher inflammatory markers, possibly as a result of increased vascularization and vascular permeability under inflammatory conditions. Bone concentrations over the MIC and AUC/MIC ratios suggested that both glycopeptides achieve a satisfactory pharmacokinetic exposure in the cancellous bone, as far as Gram-positive pathogens are concerned. On the other hand, cortical bone exposure was suboptimal in most patients. Furthermore, as antimicrobial penetration may be affected by impaired blood supply, the role of radical surgical removal of purulent and necrotic tissues appears to be essential in order to shorten treatment duration and to reduce the risk of treatment failure.

[Can iatrogenic air embolism related to intraoperative use of hydrogen peroxide be easily avoided?]. / Embolie gazeuse iatrogène due à l'utilisation peropératoire d'eau oxygénée: un accident facilement évitable?

Air embolism is a rare complication of intraoperative use of hydrogen peroxide. We present the case of a young girl who underwent surgery for septic nonunion of the femur and developed this complication postoperatively. Outcome was fortunately favorable. A review of the surgery and anesthesia literature revealed the pathogenic mechanism of this type of accident together with the appropriate diagnostic and therapeutic practices. We propose here a series of preventive measures based on our experience and data in the literature: inform the anesthetist before using hydrogen peroxide, use a cup instead of a syringe for administrating hydrogen peroxide and avoid use in deep highly vascularized cavities.

[Application of gentamycini impregnated polymethylmethacrylate (PMMA) (Septopal) in treatment of infected nonunion. Own experiments]. / Wykorzystanie implantów z polimetylmetakrylanu (PMMA) jako nosnika gentamycyny (Septopal) w leczeniu zakazonych stawów rzekomych. Badania wlasne.

INTRODUCTION: Treatment techniques of osteomyelitis and infected nonunion require local antibiotic-therapy in the infection places because of the necessity of achievement of a very high concentration of antibiotic. Among the methods of local application of antibiotic we have the possibility of non-absorbale carriers application where polymethylmethacrylate (PMMA) is the carrier. Aminoglycosides are the most commonly employed antibiotics for use with PMMA. PURPOSE OF THE WORK: Estimation of the possibility of use gentamycini-impregnated polymethylmethacrylate (PMMA) (Septopal) in treatment of infected nonunion. MATERIAL AND METHODS: In the years 2001-2006 in Clinic of Traumatology and Hand Surgery in Wroclaw Medical University, 16 patients were treated because of osteomyelitis and infected nonunion of the long bone. Osteomeylitis, according to the Cierny-Mader's classification, was determined as type IVA in 8 patients, as type IIIA in 4 patients, as type IVB in 4 patients. In stage I surgical cleaning focus of the infected nonunion, external stabilization and implantation of PMMA with gentamycyni were performed, in stage II bone graft with length from 2 to 5 cm was applied. RESULTS: Eradication of the inflammatory process was achieved 13 patients, bone union-in 12 patients. The mean time of bone union achievement was 9 months. The failures concerned mainly patients with type IVB of osteomyelitis according to Cierny-Mader's classification. CONCLUSIONS: Application of PMMA with gentamycini is an efficient method in the treatment of traumatic osteomyelitis. The reults of osteomyelitis treatment correspond to the osteomyelitis classification according to Cierny-Mader. Application of PMMA with gentamycyni in connection with surgery of nonunion prevents possible infection and creates the space for bone grafts.

Vascularised bone grafts in the treatment of long bone defects.

Reconstruction of large bony defects of long bones was performed using vascularised fibular grafts in four patients at the Department of Orthopaedic Surgery of the University of Ioannina Medical School. Indications for grafting procedures in this small series had been the loss of bone due to the extensive resection of avascular and necrotic bone from septic pseudoarthrosis in three patients and congenital pseudarthrosis secondary to neurofibromatosis in a child. Primary skeletal union with graft hypertrophy occurred in three of the patients. The fourth patient had an asymptomatic nonunion at the proximal end of the graft. The result in each patient was the presence of a well-aligned limb that had normal or nearly normal motion and acceptable length.

[Infected, diaphyseal pseudoarthroses of limbs. Therapeutic problems in 17 cases. (Orthopedic-traumatology service of the University Hospital Center of Brazzaville-Congo]. / Pseudarthroses infectées diaphysaires des membres. Problèmes thérapeutiques à propos de 17 cas (Service Orthopédie-Traumatologie du Centre Hospitalier Universitaire de Brazzaville-Congo).

Seventeen cases of infected pseudarthrosis have been registered between 1987 and 1991 in the Orthopaedic Ward of the University Hospital of Brazzaville (Congo). They are distributed as follows: eleven cases located in the leg, three in the humerus, and three others in the femur. Their analysis was especially concerned with the etiological aspects of the different cases, and with their specific therapeutic strategies. The authors' conclusion points to the urge to take deterrent steps to ward off the awful complications of the disease.