DAIR in treating chronic PJI after total knee arthroplasty using continuous local antibiotic perfusion therapy: a case series study.

BACKGROUND: Antimicrobial agents are administered via intramedullary antibiotic perfusion (iMAP)/intrasoft tissue antibiotic perfusion (iSAP) to infected lesions to control osteoarticular and soft tissue infections. Continuous local antibiotic perfusion (CLAP) has been reported to be useful. This study aimed to investigate the outcomes of DAIR combined with CLAP for chronic PJI after total knee arthroplasty performed at our hospital. SUBJECTS AND METHODS: Six patients (male; one case, female; five cases, mean age 79.5 years (70-94)) underwent CLAP for chronic PJI after TKA at our hospital between July 2020 and June 2022. They were followable for at least one year after surgery. Seven months (17-219), with a mean follow-up of 24.3 months (12-36). In addition to direct debridement and insert exchange, systemic antimicrobial treatment, and CLAP with gentamicin were performed using NPWT. We investigated the organisms causing the inflammation, the duration of iMAP/iSAP implantation, the maximum daily dose of GM, the maximum GM blood concentration, and the presence or absence of GM-induced adverse events. RESULT: Two of six patients had a recurrence of infection at five weeks and five months after initial CLAP and required repeat CLAP treatment, but all patients could preserve their components. The organisms responsible for the flare-ups were MSSA in three cases: ESBL-producing E. coli, mixed MSSA and streptococcal infection, Klebsiella pneumonia in one case each, and unknown pathogens in one case. CLAP therapy for all patients was administered eight times in 6 cases: iMAP, mean: 10.0 days (5-16); iSAP, mean: 19.3 days (15-28); GM dose, mean: 162.5 mg/day (80-240); and GM blood concentration, mean: 1.4 µg/mL (0.2-5.0). Adverse events included one case of reversible acute kidney injury during CLAP in a patient with recurrent infection. DAIR with CLAP for chronic post-TKA infection can be a useful treatment option to preserve components and allow the infection to subside, provided the implant is not markedly loosened.

Nail insertion points in semi-extended nailing of tibial fractures and their influence on alignment: A retrospective cohort study comparing two nail insertion techniques.

INTRODUCTION: Semi-extended tibial nailing techniques include the extra-articular technique (EAT) and the patellar eversion technique (PET). These approaches differ regarding the exposure of the patellar retinaculum and the size of the surgical field. This study compared the postoperative alignment and intramedullary nailing entry points between the EAT and PET for tibial fractures. PATIENTS AND METHODS: A total of 54 patients (aged ≥18 years) who had undergone intramedullary nailing by the EAT (n = 29) or PET (n = 25) for a tibial shaft fracture were evaluated. The intramedullary nailing entry point and postoperative alignment were measured, and the 1-year postoperative follow-up results were compared. RESULTS: For the EAT and PET, the intramedullary nailing entry point was located at a mean distance of 4.04 mm medial to the optimal entry point and 0.27 mm lateral to the optimal entry point, respectively. The mean angular deformation observed in anteroposterior radiographs following surgery using the EAT and PET were 2.49° and 0.32° valgus, respectively. CONCLUSION: The intramedullary nailing entry point affected postoperative alignment. Intramedullary nailing may result in malalignment while performing the EAT due to the interference of the patella at the time of nailing.

Exchange Nailing as Revision Surgery for Post-operative Non-union of Atypical Femoral Fractures: A Case Report and Treatment Strategy.

INTRODUCTION: Atypical femoral fractures account for only 0.5% of femoral shaft fractures, but delayed union or non-union occurs in 50% of atypical femoral fractures accompanied by femoral lateral bowing. Such fractures are difficult to treat. CASE REPORT: The case was an 84-year-old woman. She was diagnosed post-operative non-union of atypical femoral fracture. We planned a revision surgery for post-operative non-union of the atypical proximal femoral fracture. A two-dimensional template was used to simulate the intramedullary nail (IMN). Due to the advanced femoral lateral bowing deformity, a mismatch with the nail was noted when the unaffected femur was used to construct the template. When the opposite side nail was used as a template, the nail was aligned with the medullary canal, and the tip of the nail coincided with the center of the medullary canal; hence, the opposite side nail was chosen. Radiographical assessments of healing of the fracture confirmed callus formation and complete bone union 3 months and 1 year after the operation, respectively. CONCLUSION: We found that exchange nailing as revision surgery for post-operative non-union of atypical femoral fractures combined with an IMN on the opposite side was useful.

A Long-standing Monteggia Fracture in a Child who underwent Bone Lengthening and Annular Ligament Reconstruction: A Case Report.

INTRODUCTION: Monteggia fractures are rare and account for 1% of all pediatric forearm fractures. Dislocation of the radial head with plastic deformation of the ulna is particularly rare and can be overlooked, thereby resulting in long effects. Here, we report the treatment of a case of a long-standing Monteggia fracture in a child. CASE REPORT: A 6-year-old girl who was injured by a fall was examined by a local physician. 4 weeks later, she was referred to our hospital. Plain X-ray and computed tomography revealed a long-standing Monteggia fracture. Ulnar osteotomy was performed; however, complete realignment was not achieved. Scar tissue and the annular ligament remained intact, thereby hindering complete reduction. The scar tissue surrounding the radial head was surgically removed, and subluxation was reduced. The annular ligament was reconstructed, and the ulna was lengthened by external fixation. 1 year postoperatively, the patient's elbow range of motion is good, and there has been no recurrence of radial head dislocation. CONCLUSIONS: The patient achieved good progress through the use of annular ligament reconstruction and ulnar osteotomy to straighten and anatomically realign the ulna. Post-operative repeat dislocation was avoided by reducing radial head dislocation, removing the scar tissue, and reconstructing the annular ligament.