Etiology and antimicrobial resistance patterns in chronic osteomyelitis of the tibia: an 11-year clinical experience.

PURPOSE: To analyze changes in tendency of etiology and of antimicrobial resistance patterns to most common local and systemic antibiotics in chronic osteomyelitis of the tibia (COM-T) in a Level I trauma center over an 11-year period. METHODS: A retrospective review including all patients with COM-T who were surgically treated from January 2009 to December 2019. Patients were divided into two period groups: 2009-2014 and 2015-2019. Microbiologic etiology was analyzed. Bacterial resistance patterns evaluation was based on the Magiorakos et al. classification, including proportions of multidrug-resistant organisms (MDROs, acquired non-susceptibility to at least one agent in three or more antimicrobial categories), extensively drug-resistant (XDR) and pan drug-resistant (PDR) organisms encountered. RESULTS: A total of 173 episodes of COM-T were identified. Monomicrobial infections represented 47.4% of all cases, while 28.3% had polymicrobial infections. Negative deep-bone cultures were identified in 24.3% of the patients. The most commonly isolated microorganisms were coagulase-negative Staphylococci (24.5%) and S. aureus (20.5%). No differences were found when comparing Gram-positive infections between periods (58.3% for 2009-2014 vs. 46.7% for 2015-2019; p = 0.10). Findings were similar for Gram-negative infections (37% vs. 33.7%; p = 0.62), although more polymicrobial infections were detected (24.7% vs. 33.3%, respectively; p = 0.359). MDROs were involved in 15% of the cases, with an upward trend when comparing both periods (12.8% vs. 23.6%; p = 0.07). The most-used combination of local antibiotics-glycopeptide (vancomycin) plus aminoglycoside (gentamicin or tobramycin)-was met with low rates of resistance in the most frequently isolated microorganisms. CONCLUSION: According to the results of the present study, rates of Gram-positive and Gram-negative infections remained consistent during the two study periods, but with an upward trend in MDRO and polymicrobial infections detected. The local combination of a glycopeptide plus an aminoglycoside was effective in treating the most frequently isolated microorganisms.

Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect.

INTRODUCTION: Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes. MATERIALS AND METHODS: A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. PRIMARY OUTCOMES: limb salvage rate and infection eradication. SECONDARY OUTCOMES: patient functional outcomes and satisfaction. RESULTS: Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6-600) and 5.4 cm (1-23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were "very satisfied" with the treatment outcome. CONCLUSION: A three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.

Outcomes and their predictors in suprapatellar nailing for tibia fractures. Multivariable analysis of 293 consecutive cases.

PURPOSE: Intramedullary nailing of tibial fractures is one of the most common procedures in orthopedic surgery. It can be technically demanding in proximal or distal fractures, which may be facilitated using semi-extended approaches. The aim of this study is to identify outcomes and their predictors using a semi-extended suprapatellar approach for tibial fracture nailing. METHODS: This is a retrospective cohort of 293 patients who underwent intramedullary nail fixation of a tibial fracture through a suprapatellar approach, considering a postoperative follow-up of 1 year. Data on patient's baseline characteristics, injuries, treatments, and outcomes regarding alignment, fracture union, and complications were recorded. For multivariable analysis, hierarchical binary (logistic) regression analysis was performed. RESULTS: The mean patient age was 47.7 years (SD 18.9), with 42A1 the most frequent fracture pattern (n = 98, 33.5%). Correct or anatomical alignment (≤ 5º in both planes) was achieved in 272 (92.8%) of the patients. On multivariate analysis, surgical delay ≥ 7 days (OR = 1.3, 95% CI = 1.3-8.1) and age over 50 years (OR = 3.2, 95% CI = 1.2-8.3) were found as predictors of fracture malalignment. Fracture healing was achieved in 97.6%, and reoperation rate was 6.14%. Overall complication's predictors were proximal fracture (OR = 2.8, 95% CI = 1.1-7.2), temporary external fixation (OR = 2.4, 95% CI = 1.2-4.9), and fracture malalignment (OR = 2.9, 95% CI = 1.1-7.9). CONCLUSION: The suprapatellar approach is a safe and useful technique for treating tibial fractures, leading to no less than correct reduction in almost all patients and achieving a high fracture healing rate, at very low rates of complications. Pre- and postoperative predictors identified must be taken into account to improve outcomes while treating these fractures.

Iliopsoas impingement after total hip arthroplasty: Does the CT-scan have any role? Our Algorithm proposal.

Introduction: The first surgical option considered in managing iliopsoas impingement following THA is endoscopic/arthroscopic iliopsoas tenotomy, because of its low risk and minimal invasiveness. Acetabular revision is a much more aggressive surgery, recommended only in cases of substantial cup malposition. However, there are no clear indications for this procedure. The purpose of this article is to analyse the role of CT-scan measurement of acetabular cup positioning in a therapeutic algorithm for iliopsoas impingement. Methods: In this retrospective observational study, we reviewed 25 patients treated for iliopsoas impingement following THA between 2011 and 2019. We studied acetabular cup positioning using CT-scan. We compared radiological parameters of patients who presented with significant clinical improvement with conservative treatment and with tenotomy against those who did not. Finally, we developed a proposed therapeutic algorithm. Results: Forty-eight percent of patients presented a significant clinical improvement following conservative treatment. Patients who did not improve were found to have greater acetabular cup axial and sagittal overhang (p-values 0.016 and 0.003). These patients were considered for tenotomy. Of this group, those who did not improve with surgery (38%) showed greater axial overhang (p-value 0.005). Conclusions: Conservative management should be the first line of treatment. In cases of non-operative treatment failure, axial acetabular cup overhang measured by CT-scan can be a useful tool in choosing between iliopsoas tenotomy or cup-revision surgery in selected cases of very severe acetabular malposition. A cut-off point of 10 mm of axial overhang is a reliable predictor of higher failure risk with iliopsoas tenotomy.