Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls.

Background Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps. Methods A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous-medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed. Results Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery. Conclusion The propeller-perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.

Prosthetic fitting associated with better survival at 5 years after above-knee amputation due to vascular insufficiency.

BACKGROUND: Individuals requiring non-traumatic Gritti-Stokes amputation or mid-thigh amputation usually have multiple comorbidities that place them at high risk of mortality. OBJECTIVE: To determine survival rate 5 years after Gritti-Stokes and mid-thigh amputation in individuals with vascular insufficiency and to identify the predictors of survival. METHODS: We conducted a retrospective observational study including all individuals with vascular insufficiency who underwent amputation from September 2007 to December 2015 in our University Hospital. The indication for amputation was limb necrosis in 86% of cases, infection in 10%, and complications with the stump (discomfort, neuroma or scar dehiscence) in 4%. Medical records were analysed to determine factors and comorbidities. The date of death was retrieved from the national death registry at a minimum of 5 years after amputation. Cox proportional-hazard regression was used to estimate associations between factors and post-amputation survival with hazard ratios (HR) and 95% confidence intervals (CIs). RESULTS: We included 126 people with vascular insufficiency (83 men), mean age was 70 years [20; 97]; eighty-nine participants (71%) died during the study period. Survival rate was 68% at 1 year, 48% at 3 years and 37% at 5 years. Survival was associated with prosthetic fitting (HR 0.306 [95% CI 0.180; 0.521], p<0.001) and length of stay (HR 0.992 [95% CI 0.987; 0.997], p = 0.003). Conversely, limb necrosis was associated with a lower survival rate (HR 3.801 [95% CI 1.615; 8.949], p = 0.002). In a secondary multivariable analysis, Gritti-Stokes amputation was the only factor positively associated with prosthetic fitting (odds ratio 7.407 [95% CI 2.439; 22.489], p<0.001). CONCLUSIONS: The survival rate at 5 years after Gritti-Stokes and mid-thigh amputation in people with vascular insufficiency was 37%. Prosthetic fitting was independently associated with better survival, and Gritti-Stokes amputation was the only factor positively related to prosthetic fitting.

Fusion rate of 89% after knee arthrodesis using an intramedullary nail: a mono-centric retrospective review of 48 cases.

PURPOSE: Knee arthrodesis is an established procedure for limb salvage in cases of recurrent infection, total knee arthroplasty soft tissue defect, poor bone stock or a deficient extensor mechanism. Surgical options include compression plate, external fixator and arthrodesis nail. Different types of nail exist: long fusion nail, short modular nail and bridging nail. This study presents the results on knee arthrodesis using different types of intramedullary nails. The aim is to assess if a specific type of nail has a better fusion rate, clinical outcome and lower complication rate. METHODS: A mono-centric retrospective study of 48 knees arthrodesis was performed between 2000 and 2018. 15 T2™ Arthrodesis Nail, 6 OsteoBridge® Knee Arthrodesis and 27 Wichita® fusion nail were used. The mean clinic and radiological follow-up was 9.8 ± 3.8 years (2.6-18 years). RESULTS: Fusion rate was 89.6%. Time to fusion was 6.9 months. Mean Parker score was 6.9/9 points. Visual Analogic Scale was 1.9. The Wichita® fusion nail showed better results in terms of fusion, time to fusion and clinical outcome measured by Parker score and VAS but without statistical significance. The early revision rate was 10.4% and 20.8% presented a late complication requiring a surgery, due to nonunion or infection. 93.3% of infection was cured. Two patients live with a fistula (4.2%) and 1 was amputated (2.1%). CONCLUSION: Although burdened by a big complication rate, knee arthrodesis with an intramedullary nail provides satisfactory results and is a good alternative to above-knee-amputation. The Wichita® fusion nail shows a tendency to better results compared to the two other nails. LEVEL OF EVIDENCE: Case series, level IV.

Locoregional anesthesia for post-operative pain management in microsurgical reconstruction of the lower extremities: A retrospective study.

OBJECTIVE: Opioid-based analgesia is often used in the management of postoperative pain in arthroplasty cases. This article analyses the safety of single-shot peripheral nerve block (PNB) and potential analgesic benefits in patients undergoing lower limb free flap reconstruction. METHODS: A retrospective review including all patients undergoing lower limb reconstruction with free flaps between October 2017 and April 2020 was performed. Patients were divided into two groups based on PNB utilization. The use of oral opioids, post-operative pain scores, flap-related outcomes, patient morbidity, and length of hospital stay (LOS) were compared between groups. RESULTS: Thirty-one patients who underwent lower limb reconstruction with free flaps, were finally included in the study. Preoperative PNB was performed on 14 patients, while 17 patients received general anesthesia (GA) alone. Pain at rest, measured using the visual analog scale (VAS) score, was significantly lower (2.2 ± 1.7 vs. 4.9 ± 1.7) in the PNB group on postoperative day 1 (POD). The mean [median]±SD amounts of opioids consumed in morphine milligram equivalent (MME) were significantly lower in the PNB group on both POD1 (33.5 [22.5] ± 33.9 vs. 61.6 [48.0] ± 39.0), POD2 (29.0 [15.0] ± 29.2 vs. 58.0 [52.5] ± 37.0) and cumulatively over 7 days (164.0 [197.0] ± 132.8 vs. 315.4 [225] ± 203.2). Complication rates and LOS were not statistically different between groups, although trending toward lower take-back procedures and major complications in the PNB group. CONCLUSION: Preoperative single-shot PNB significantly reduced postoperative opioid use and patient-reported pain severity and was not associated with an increase in complication rates.

Effectiveness of an Online Course on Fracture-Related Infections.

This study aims to evaluate the effectiveness of an online course to enable orthopaedic surgeons to acquire the core competencies necessary to prevent and treat fracture-related infections (FRI). This study included orthopaedic surgeons and residents from Latin American countries who attended an online course focused on FRI. The online course included: didactic lectures, small-group clinical case discussions, and panel case discussions. The course was delivered using Zoom® platform and designed to address four core competencies: prevention, definition and diagnosis, antimicrobial therapy, and surgical treatment. An online questionnaire was created distributing 16 questions through six clinical scenarios. Participants were invited to answer the questionnaire before and after the course. Sixty of the 78 course participants answered the pre-course, and 42 the post-course assessment. Relative to before the course, the mean post-course assessment score rose significantly for prevention of FRI (4.1 before and 4.5 after; p = 0.014), definition and diagnosis (2.4 before and 3.4 after; p = 0.001), and surgical treatment (2.2 before and 2.8 after; p = 0.011). The final score encompassing all four core competencies also rose significantly (2.7 before and 3.3 after; p = 0.001). The online course on FRI was feasible and effective, significantly increasing course users' knowledge of overall competency in managing FRI.

Should all patients with a culture-negative periprosthetic joint infection be treated with antibiotics? : a multicentre observational study.

AIMS: The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld. METHODS: A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years. RESULTS: None of the acute PJIs and 70 of the chronic PJIs (4.7%) were culture-negative; a total of 36 culture-negative PJIs (51%) were treated with antibiotics, particularly those with histological signs of infection. After two years of follow-up, no recurrent infections occurred in patients in whom antibiotics were withheld. The requirement for removal of the components for any indication during follow-up was not significantly different in those who received antibiotics compared with those in whom antibiotics were withheld (7.1% vs 2.9%; p = 0.431). CONCLUSION: When adequate methods of culture are used, the incidence of culture-negative PJIs is low. In patients with culture-negative PJI, antibiotic treatment can probably be withheld if there are no histological signs of infection. In all other patients, diagnostic efforts should be made to identify the causative microorganism by means of serology or molecular techniques. Cite this article: Bone Joint J 2022;104-B(1):183-188.

[Diagnosis and management of chronic osteomyelitis of long bones in adults]. / Diagnostic et prise en charge de l'ostéomyélite chronique des os longs chez l'adulte.

Chronic osteomyelitis is an inflammatory process of the bone caused by an infectious agent. This condition leads to altered bone vascularization and thus to bone destruction and formation of necrotic bone fragments (sequestrum). The treatment of chronic osteomyelitis is primarily based on surgical management, which includes debridement of the sequestrum and sampling of bone tissue for microbiological analysis in order to initiate a targeted antibiotic therapy. A multidisciplinary approach is essential, involving expertise in orthopedic surgery, musculoskeletal imaging and nuclear medicine, infectious diseases, as well as plastic or vascular surgery for complex cases with soft tissue and/or vascular defects.

L'ostéomyélite chronique est un processus inflammatoire osseux causé par un agent infectieux. Cette pathologie provoque une altération de la vascularisation intraosseuse et périostée donnant lieu à des fragments d'os nécrotiques (séquestres). Le traitement de l'ostéomyélite chronique repose sur une prise en charge chirurgicale permettant de débrider les séquestres et de réaliser des prélèvements osseux pour des analyses microbiologiques afin d'instaurer une antibiothérapie ciblée sur l'agent pathogène. Une approche multidisciplinaire doit impliquer une expertise en chirurgie orthopédique, en imagerie musculosquelettique et médecine nucléaire, en maladies infectieuses, ainsi qu'en chirurgie plastique ou vasculaire pour les cas avec perte des tissus mous ou défaut de vascularisation.

Traumatic abdominal wall hernias: disruptions of the abdominal wall muscles associated to pelvic bone fractures illustrated by two case reports.

BACKGROUND: Blunt abdominal traumas are often associated with intra-abdominal injuries and pelvic fractures. Traumatic abdominal wall hernias due to disruption of the abdominal wall muscles may be overlooked. Delayed diagnosis can lead to hernia related complications. CASE PRESENTATION: We present two cases of high kinetic trauma with pelvic fractures and acute traumatic abdominal wall herniation. Both of these cases suffered from a delayed diagnosis and needed surgery to treat the symptomatic herniation. CONCLUSION: Clinical reassessment and appropriate medical imaging are mandatory in patients with high kinetic abdominal blunt traumas and associated pelvic fracture, in order to prevent delayed diagnosis and possible complications.

Septic arthritis of the shoulder due to Ureaplasma urealyticum after emergency caesarean section: a case report.

BACKGROUND: Ureaplasma urealyticum is an intra-cellular bacterium frequently found colonizing the genital tract. Known complications include localized infections, which can result in premature deliveries. Septic arthritis due to U. urealyticum in healthy patients is exceptionally rare, although opportunistic septic arthritis in agammaglobulinemic patients have been reported. However, there are no reports of septic arthritis due to U. urealyticum following caesarean section or in the post-partum period. CASE PRESENTATION: A 38-year-old immunocompetent woman presented with severe right shoulder pain, 1 month following emergency caesarean section at 26 weeks of gestation for pre-eclampsia and spontaneous placental disruption with an uncomplicated post-operative recovery. Our suspicion of septic arthritis was confirmed with abundant pus following arthrotomy by a delto-pectoral approach. Awaiting culture results, empirical antibiotic treatment with intravenous amoxicilline and clavulanic acid was initiated. In spite of sterile cultures, clinical evolution was unfavorable with persistent pain, inflammation and purulent drainage, requiring two additional surgical débridement and lavage procedures. The 16S ribosomal RNA PCR of the purulent liquid was positive for U. urealyticum at 2.95 × 106 copies/ml, specific cultures inoculated a posteriori were positive for U. urealyticum. Levofloxacin and azithromycine antibiotherapy was initiated. Susceptibility testing showed an intermediate sensibility to ciprofloxacin and clarithromycin. The strain was susceptible to doxycycline. Following cessation of breastfeeding, we started antibiotic treatment with doxycycline for 4 weeks. The subsequent course was favorable with an excellent functional and biological outcome. CONCLUSIONS: We report the first case of septic arthritis due to U. urealyticum after caesarean section. We hypothesize that the breach of the genital mucosal barrier during the caesarean section led to hematogenous spread resulting in purulent septic arthritis. The initial beta-lactam based antibiotic treatment, initiated for a purulent arthritis, did not provide coverage for cell wall deficient organisms. Detection of 16S rRNA allowed for a correct microbiological diagnosis in a patient with an unexpected clinical course.

Outcomes of combined hip procedure with dual mobility cup versus osteosynthesis for acetabular fractures in elderly patients: a retrospective observational cohort study of fifty one patients.

PURPOSES: Acetabular fractures are more and more common in the elderly. Open reduction and internal fixation (ORIF) may lead to poor outcomes and high revision rates. Primary total hip arthroplasty (THA) combined with internal fixation, also known as the combined hip procedure (CHP), associated with dual mobility cup (DM-CHP) could be an efficient procedure in selected elderly patients. The aim of this study is to compare functional and radiological outcomes between ORIF and DM-CHP. METHODS: Between 2007 and 2018, 51 patients older than 65 years were surgically treated for acetabular fractures. Twenty-six patients were treated by DM-CHP and 25 by ORIF. Each group was divided into two subgroups regarding a single or combined approach. Hospital stay, surgical time, intraoperative blood loss, and complications were documented. The Harris Hip Score (HHS) was used for measuring the functional outcome. Radiological analysis was used to assess the centre of rotation in the DM-CHP group. RESULTS: Median surgery time and intra-operative blood loss were higher in DM-CHP than those in ORIF. Early medical complication rate was higher for a combined approach as compared with a single posterior approach in DM-CHP (p = 0.003). Dislocation rate was 7.7% in DM-CHP. Revision rate was higher in ORIF (20% versus 7.7%). HHS was similar in both groups. CONCLUSIONS: DM-CHP leads to similar functional outcomes and less revision than ORIF. This study strengthens the practice of using only the posterior approach for primary THA in the elderly. Dual mobility is a valid therapeutic option for acetabular fractures in elderly patients.

Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study.

Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.

Results of open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable pelvic ring injuries: retrospective study of 36 patients.

INTRODUCTION: Surgical stabilization of posterior pelvic ring fractures can be achieved by closed reduction and percutaneous fixation (CRPF) or by open reduction and internal fixation (ORIF). The aim of the present study is to compare the clinical results of both methods. MATERIAL AND METHODS: Medical records of 36 patients consecutively operated for unstable pelvic ring injuries were retrospectively reviewed. We compared 22 patients treated with CRPF versus 14 patients stabilized by using ORIF between 2007 and 2017. The Majeed and Pohlemann scores were used to evaluate postoperative functional outcomes. Complications like blood loss, infection rate, Neurological injury, the operative time and the length of hospital stay were analyzed. RESULTS: The median Majeed pelvic score was 87 points for the CRPF technique compared with 69 points for the ORIF technique. The median Pohlemann score, operative time and length of hospitalization were similar between the two groups. The median blood loss for the CRPF technique was 300 ml compared to 500 ml for the ORIF technique. CRPF and ORIF procedure had each one neurological lesion. There was one case of infection in the ORIF group and none in the CRPF group. No measurements except for the blood loss have reached the significance threshold. CONCLUSION: The CRPF technique shows a clear decrease in blood loss. There was no statistically significant difference in the functional results, infection rate, neurological injury, operative time and hospital stay between both techniques.

Cross-cultural adaptation and measurement properties of the French version of the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R).

BACKGROUND: The Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) is a self-administered questionnaire to measure multidimensional adjustment to a prosthetic limb. Our aim was to assess the validity and reliability of the French version of the TAPES-R (TAPES-R-F). MATERIALS AND METHODS: The cross-cultural adaptation was performed according to the recommendations. Factor analysis and Rasch analysis were also performed to allow comparison with the original English version. Construct validity was assessed by measuring the correlations between TAPES-R-F subscores and quality of life, pain, body image satisfaction, anxiety and depression. Internal consistency was measured with Cronbach's α. The standard error of measurement, smallest detectable change, Bland and Altman limits of agreement, and intraclass correlation were the measures of agreement and reliability. RESULTS: No major difficulties were encountered throughout the trans-cultural adaptation process. The final version of the TAPES-R-F was well accepted and understood by the patients. According to the factor analysis, the satisfaction scale should be treated as a one-dimensional construct when used by French-speaking people and should not be separated into two separate subscales, functional and aesthetic, as is the case in the original English version. Our study confirmed that there is a strong relationship between biopsychosocial factors and adjustment to amputation. Cronbach's α > 0.8 for all the subscales. Reliability was good to excellent for all the subscales (ICCs between 0.61 and 0.89). The smallest detectable changes were 0.7, 0.8, 1.3, 0.4, and 1.8 (general adjustment, social adjustment, adjustment to limitation, activity restriction, and global satisfaction with the prosthesis). CONCLUSIONS: The TAPES-R-F is a valid and reliable instrument to assess multidimensional adjustment of French-speaking lower limb amputees. This questionnaire can be used for both clinical assessment and research purposes.

Practical guidelines for the treatment of patellar fractures in adults.

The role of the patella is paramount in the transmission of the quadriceps muscle forces, the increase of the lever arm, the distribution of the forces on the trochlea and the centring of the extensor apparatus. Despite the low incidence of patellar factures in comparison with other lower limb fractures, the painful and functional complications, such as knee stiffness, loss of extension and patellofemoral osteoarthritis, can be very disabling and will often compromise the return to a professional or recreational activity and induce falls in the elderly population. Treatment can be conservative or surgical, provided that it is adapted to the type of fracture. Undisplaced fractures with an intact extensor mechanism can be treated nonoperatively. Surgical treatment is recommended for fractures that either disrupt the extensor mechanism or have more than 2 to 3 mm of step-off and more than 1 to 4 mm of displacement. Tension band fixation is the most commonly employed surgical technique. In most cases, hardware has to be removed after fracture healing because of implant-related pain. Operative treatment of comminuted patellar fractures presents a significant challenge to surgeons. Failure to restore the articular surface contour results in posttraumatic arthritis. Anatomical reconstruction of the articular surface is the only way to prevent the development of posttraumatic osteoarthritis. Typically, fracture classification and thus treatment choice are based on anteroposterior and lateral radiographs of the knee, but when computed tomography of the knee was performed pre-operatively, both the classification and treatment were modified thanks to a better understanding of the fracture complexity. The purpose of this article is to review current treatment strategies and optimise the management of adult patients with patellar fractures.

Cross-cultural adaptation and validation of the ABIS questionnaire for French speaking amputees.

Background: The Amputee Body Image Scale (ABIS) and its shortened version (ABIS-R) are self-administered questionnaires to measure body image perception of amputee. Our aim was to assess the validity and reliability of the French ABIS (ABIS-F and ABIS-R-F).Methods: Ninety-nine patients were included. The cross-cultural adaptation was performed according to the recommendations. Construct validity was assessed by measuring the correlation between ABIS-F or ABIS-R-F scores and quality of life, pain, anxiety, and depression. Internal consistency was measured with Cronbach's α. The standard error of measurement, smallest detectable change, Bland and Altman limits of agreement, and intraclass correlation were the measures of agreement and reliability.Results: A highest body image disturbance was associated with lowest quality of life, higher pain, and higher anxiety, and depression. Cronbach's α was 0.91/0.89 (ABIS-F/ABIS-R-F). The standard error of measurement was 5.35/2.28 (ABIS-F/ABIS-R-F). The smallest detectable change was 14.82/6.31 (ABIS-F/ABIS-R-F). The mean difference in ABIS-F score was -3.90 with limits of agreement from -18.71 to 10.92. For ABIS-R-F, the mean difference was -2.12 with limits of agreement from -8.43 to 4.19. Intraclass correlation was 0.87/0.82 (ABIS-F/ABIS-R-F).Conclusions: The French versions ABIS-F and ABIS-R-F share similar psychometric properties, both are as reliable, but ABIS-R-F has a better response structure and is more feasible.Implications for rehabilitationThe quality of life of amputees is impacted by their satisfaction with body imageThe Amputee Body Image Scale questionnaire measures this perception and is available for French-speaking amputeesThe Standard Errors of Measurement proposed could be useful for clinical and research purposesBoth ABIS and ABIS-R showed satisfactory construct validity, internal consistency, and reliabilityThe shortened version has a better response structure and is more readily feasible.

General treatment principles for fracture-related infection: recommendations from an international expert group.

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.

Advanced septic arthritis of the shoulder treated by a two-stage arthroplasty.

BACKGROUND: The usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited. AIM: To evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint. METHODS: We retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage. RESULTS: Mean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively. CONCLUSION: Short interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.

Prosthetic-joint Infections: Mortality Over The Last 10 Years.

Background: There is a constant increase of joint arthroplasties to improve the quality of life of an ever-aging population. Although prosthetic-joint infections are rare, with an incidence of 1-2%, they represent a serious complication in terms of morbidity and mortality. Infection related mortality is known to be approaching 8% at one year. The aim of this retrospective study is to reassess the one and two-year mortality over the last ten years. Methods: Patients treated for prosthetic joint infection at the University Hospital of Lausanne (Switzerland) between 2006 and 2016 were included. The one and two-year cumulative mortality depending on sex, age, type of prosthesis, infecting organism and type of surgical treatment were computed. Results: 363 patients (60% hips, 40% knees) were identified with a median age of 70 years. The one-year cumulative mortality was 5.5% and it was 7.3% after two years. No difference was seen between hip and knee prostheses, but the mortality was higher in men than in women and increased with age. Furthermore, there was a significant difference depending of the germ with enterococci infections associated with a higher risk of death. Finally, patients treated with a one-stage or two-stage exchange had a lower mortality than those treated with debridement and retention. Conclusion: The mortality is still high and differs according to sex, age, infecting organism and type of surgical treatment. There is a need of studies to improve the management of patients at risk of increased mortality.

Infection after fracture fixation.

Infection after fracture fixation is a feared complication in orthopaedic surgery leading to poor bone healing and loss of function.Early detection is essential and interdisciplinary care is mandatory.Eradication of infection is only possible through combined surgical and antibiotic treatment.Intraoperative tissue samples must be taken and are effective for guidance of the antibiotic regimen.Infection after fracture fixation is different from prosthetic joint infection (PJI) and needs a specific strategy.In this review, we define infection after fracture fixation, and outline the clinical, radiological and laboratory signs of these infections, as well as a treatment algorithm for optimal patient care. Cite this article: EFORT Open Rev 2019;4:468-475. DOI: 10.1302/2058-5241.4.180093.