ABSTRACT
PURPOSE: Fracture-related infections (FRI) pose a difficult management problem, as they require numerous surgical interventions and extended antibiotic treatments, especially when a multidrug-resistant organism is involved, with a paucity of available literature that provides guidance. RESULTS: A 42 year-old male presents an open diaphyseal tibia and fibula fracture, complicated by soft tissue necrosis and infections caused by extensively drug-resistant Acinetobacter baumannii (XDR-Ab). Initially treated with a damage control external fixator, the patient underwent multiple surgical procedures, including radical debridement, negative pressure wound therapy, external fixator revisions and reconstructive surgery using a latissimus dorsi free flap. The emergence of colistin resistance in the Acinetobacter baumannii strain led to the compassionate use of cefiderocol, finally achieving clinical cure. CONCLUSIONS: This case report is one of the firsts that highlights the potential efficacy of cefiderocol in treating challenging bone and joint infections sustained by XDR-Ab. The successful outcome also emphasizes the importance of a comprehensive, multidisciplinary approach in achieving favorable results in complex FRI.
ABSTRACT
PURPOSE: In cruciate retaining total knee arthroplasty, posterior cruciate ligament damage may occur during tibial cutting. A prospective randomized study was conducted to investigate whether a novel tibial cutting technique was more effective than the currently used techniques. MATERIALS AND METHODS: Patients undergoing cruciate retaining total knee arthroplasty were recruited in a prospective, randomized, controlled trial. In 25 patients (group 1) the tibial cut was performed using a double tibial cut technique; in 25 (group 2) and 25 (group 3) patients, the bone island and en bloc resection techniques were performed, respectively. Posterior cruciate ligament integrity and femoral rollback were assessed at the end of surgery. The Oxford Knee Score, WOMAC score and range of motion were assessed postoperatively. RESULTS: Posterior cruciate ligament was completely preserved in 92% of patients in group 1 and in 64% in group 2 and 3, respectively (p = 0.03). The Oxford Knee Score and WOMAC scores did not differ between groups (p = 0.4). The mean knee flexion was 126.4°, 121.5° and 123.9° in groups 1, 2 and 3, respectively (p = 0.04). The femoral rollback at 120° flexion was 80.7%, 72.2% and 75.4% in groups 1, 2 and 3, respectively (p = 0.01). CONCLUSIONS: The double cut technique preserves the posterior cruciate ligament at significantly higher rates than the bone island or en bloc resection techniques. Better posterior cruciate ligament preservation may improve the femoral rollback and knee flexion. LEVEL OF EVIDENCE: Prospective randomized controlled trial, Level I.
ABSTRACT
Prosthetic joint infection (PJI) and fracture-related infection (FRI) are difficult-to-treat conditions in patients with severe comorbidity or significant surgical risk. In cases not eligible for standard strategy, debridement procedures with the retention of prosthesis or internal fixation device, combined with long-term antibiotic treatment and subsequent indefinite chronic oral antimicrobial suppression (COAS), can be the only reasonable choice. The aim of this study was to investigate the role of COAS and its follow-up in the management of these cases. We retrospectively analyzed a cohort of 16 patients with a follow-up of at least 6 months (mean age 75 yo, 9F, 7M, 11 PJI, 5 FRI). All microbiological isolates were tetracycline-susceptible staphylococci and for this reason a minocycline-based COAS was adopted after debridement and 3 months of antibiogram-guided antibiotic treatment. Patient monitoring was carried out on a clinical basis, with bimonthly execution of the inflammation indices and serial radiolabeled leukocyte scintigraphy (LS). The overall median time of COAS follow-up was 15 months (min 6-max 30). Moreover, 62.5% of patients were still taking COAS with no relapse after cure at the last evaluation available. Clinical failure with a relapse of the infection was observed in 37.5% of patients; interestingly, 50% of them had previously stopped COAS due to side effects of the antibiotic used. In the COAS follow-up, a combination of clinical, laboratory and LS evaluation seems to monitor the infection properly. COAS can be considered as an interesting approach in patients not suitable for standard treatments of PJI or FRI but it requires careful monitoring.
ABSTRACT
Local antibiotic delivery strategies have been increasingly employed for the prevention of fracture-related infections (FRIs). The aim of this study is to evaluate the efficacy and safety of antibiotic-coated implants in the prevention of FRIs after surgical treatment in patients with increased infectious risk. A retrospective observational study has been conducted on patients with upper and lower limb fractures treated with internal fixation or prosthetic replacements, using a gentamicin coated nail (CN) and/or antibiotic-loaded hydrogel applied to the implant of choice (ALH). The study included 37 patients (20 M, 17 F), with a mean age of 63 years. The mean estimated preoperative infectious risk score was 6.4%. ALH was used in 27 cases, tibial CNs were implanted in 4 cases, and both were employed in 6 cases. The antibiotics used locally were gentamicin in 72.97% of cases (27 patients) and a combination of gentamicin + vancomycin in 27.03% of cases (10 patients). Mean follow-up was 32 months. Only one case (2.94%) showed onset of FRI at 5 months after surgery. Local antibiotic prophylaxis by coating resulted in a reduction in the incidence FRI, as compared to the estimated preoperative risk. The use of ALH allows for the choice of antibiotic; however, the application of antibiotics seems more nonuniform when applied to a nail.